How should one satisfy the situational rule in Loop 2310B when CPT code 36415 is submitted in the line level of a claim?
The TR3 for the X12 837 Institutional claim includes a situational rule stating that Loop 2310B (Operating Physician Name) is required, “when a surgical code is listed on this claim”. RFI numbers 2230 and 1601 reinforce this.
The AMA has designated all CPT codes between 10000–69990 as “surgical codes.” A blood draw, as represented by code 36415, although surgical, does not require an operating physician. This is implied when contrasting the following CPT codes:
• CPT Code 36410 ("venipuncture…necessitating the skill of a physician…") as published by the AMA in CPT 2023, p. 291
• CPT Code 36415 ("…for all routine venipunctures, not requiring the skill of a physician…") as communicated by CMS through local coverage determinations in LCA52470.
Based on this information, the Loop 2310B situational rule cannot be satisfied when using CPT code 36415 at the line level.
The designation of which CPT codes are surgical is outside the purview of X12. The submitter of this RFI should consult the AMA as the CPT code set maintainer and review all CPT front matter information about the interpretation of surgery vs. non-surgery procedure codes.