36415
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For CPT 36410 claims, submit ICD-10-CM code I87.8, I99.8, or R68.89 on all claims to justify physician-skill venipuncture.
- When services require a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- If an Advance Beneficiary Notice (ABN) is used for anticipated denials under reasonable and necessary provisions, attach Form CMS-R-131 signed by the beneficiary and report modifier GA (or GA if patient refused to sign but was properly witnessed); Part A claims require occurrence code 32 and the date of the ABN when GA is used.
- Use modifier GX when a voluntary notice of liability was issued under payer policy for anticipated denials based on non-medical-necessity reasons; an ABN is not required for GX.
Key Coverage Criteria
- Submit CPT 36415 for routine venipuncture of superficial peripheral veins of the upper or lower extremities and for all routine venipunctures not requiring physician skill.
- Submit CPT 36410 for venipuncture necessitating physician skill when performed by a physician on neck veins (external or internal jugular), deep (central) thoracic veins (e.g., subclavian), or groin veins (e.g., femoral).
- Submit CPT 36410 for venipuncture of superficial extremity veins only when a qualified individual's (e.g., nurse, phlebotomist, medical technician) demonstrated attempts were insufficient and physician skill was necessary.
- Venipuncture necessitating physician's skill (CPT 36410) is payable under Medicare Part B when performed in listed places of service including Office (11), Home (12), Assisted living (13), Mobile unit (15), Urgent care (20), Inpatient hospital (21), Outpatient hospital (22), ER (23), Skilled nursing facility (31), Nursing facility (32), and Clinic (49).
- Perform peripheral venous ultrasound to evaluate clinical signs or symptoms suggestive of acute or new-onset deep vein thrombosis (e.g., extremity swelling, tenderness, erythema).
- Perform venous ultrasound to investigate DVT as the source of a confirmed pulmonary embolism.
9 Active Policies
L33693 — Peripheral Venous Ultrasound
J09
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
J12
L37371 — Electroretinography (ERG)
J12
L35007 — Vestibular and Audiologic Function Studies
J12
L35434 — Oximetry Services
Related Codes
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