Specimen Collection and Travel Allowance Fees - JE Part B

Specimen Collection Fees and Billing

• Only one collection fee per day will be allowed for each patient encounter/trip.
• A specimen collection fee is not allowed when the cost of collecting the specimen is minimal, such as a throat culture or a routine capillary puncture for clotting or bleeding time.
• A specimen collection fee is not allowed when the service requiring the collection is not covered due to not being reasonable and necessary or because it is excluded from coverage for other reasons.
• In the outpatient setting, the patient typically obtains a stool sample for an occult blood test at home and a fee for such collection is not allowed.
• A specimen collection fee may be allowed when it is medically necessary for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient when:
  • The technician personally draw the specimen (e.g., venipuncture or urine sample by catheterization).
  • The facility did not have on duty personnel qualified to perform this service.
• When a laboratory obtains the specimen collection in the home place of service (POS 12 or 14) or in the nursing facility (POS 13, 32, 33 or 54), payment may be received for both the draw and for the associated travel to obtain the specimen(s) for testing.

Independent Laboratory

• When an independent laboratory obtains a specimen for a homebound or institutionalized patient, the homebound indicator must appear in Loop 2300, CRC/75, 03 for electronic claims. For paper claims, the statement "Homebound" must appear in Item 19 of the CMS-1500 claim form. Claims submitted without this information will be rejected as unprocessable (remark code MA130).
• A patient will be considered homebound if he/she has a condition due to an illness or injury that restricts his/her ability to leave the residence except with the aid of supportive devices (such as crutches, canes, wheelchairs, and walkers): the use of special transportation; the assistance of another person; or if leaving home is medically contraindicated.

Specimen Collection Codes

Travel Allowance

• Travel allowance may be made in addition to a medically necessary specimen collection fee when the specimen is collected from a nursing home or homebound patient.
• Independent laboratories must submit HCPCS code P9603 (per mile) or P9604 (flat rate) for each patient encounter for places of service:
  • 12 - home
  • 13 - assisted living facility
  • 14 - group home
  • 31 - nursing facility
  • 32 - domiciliary care
  • 33 - custodial care
  • 54 - intermediate care facility
• Claims for travel allowance submitted with place of service 81/independent lab will be denied.
• The decision is up to the provider which method to use for trips which average more than 20 miles round trip.
• No allowance will be made when a technician is acting as a messenger service to pick-up a specimen drawn by a physician or nursing home personnel.
• The travel allowance may not be paid to a physician unless the trip to the home or nursing home was solely for the purpose of drawing a specimen. Otherwise, travel costs are associated with the other purposes of the trip.
• The allowance is intended to cover the estimated travel costs of collecting a specimen and is reflecting the technician's salary and travel costs.

HCPCS and Usage

Use HCPCS P9603

• In situations where the average trip to the patient's home is longer than 20 miles round trip.
• If a specimen is drawn or picked up from a non-Medicare patient, the fee must be prorated.
• The quantity billed for must reflect the actual number of miles traveled.

Use HCPCS P9604

• To reflects a flat rate, and the quantity billed must be one (0010).
• The flat rate travel fee must be prorated when more than one blood draw is performed at the same address and for stops at the homes of Medicare and non-Medicare patients. The claim must be submitted based on the total number of patients seen on that trip.

CPT 84999

• A payment may be allowed to cover the additional costs of travel to collect a specimen from a nursing home or homebound patient when clinical diagnostic laboratory tests are needed on an emergency basis outside the general business hours of the laboratory making the collection, submit charges for this service with CPT code 84999.
• This code must be submitted with a narrative description of "Emergency, after hours travel allowance" and the information must be submitted in Loop 2300, or 2400, NTE, 02 for electronic claims or as an attachment to the CMS-1500 claim form.

HCPCS Modifier LR

• Laboratories should submit HCPCS modifier LR (informational purposes only) to indicate "Round Trip" on HCPCS code P9604.

Resources

• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 180
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 60