Medical Coding

Category - 30,000 Series

A 14-year-old patient with an abscessed tooth presented to the physician’s office with possible sepsis. The tooth had gone untreated for two weeks, and now the patient is experiencing a high fever, severe headaches and toothaches and malaise and fatigue. The physician suspects that the bacteria from the tooth has spread to the patient’s blood and is now a systemic infection. As part of the office procedure, the physician orders a CBC in order to examine the bacterial levels in the patient’s blood. After the physician writes the orders, the nurse performs a venipuncture on the patient in order to obtain a blood sample. What is the correct code for the collection of the blood only?
  1. 36416
  2. 36415
  3. 36410
  4. 36406
Explanation
Answer: B - The correct code for the collection of the blood is 36415 (Collection of Venous Blood by Venipuncture). This code is used when a nurse performs the venipuncture in the office, for the purposes of collecting a blood sample. Code 36416 refers to a capillary blood sample that is obtained from the tip of the finger or heel of an infant. Codes 36406 and 36410 are used for the collection of blood when it necessitates the skill of a physician not a nurse
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