Specimen Collection and Travel Allowance Fees

Specimen Collection Codes

Specimen Collection Fees

• Only one collection fee per day will be allowed for each patient encounter/trip regardless of the number of specimens drawn
• 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. This fee will not be paid to anyone who has not extracted the specimen.
• 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
• To be eligible for a specimen collection fee, the specimen must be:
  • Used to perform a clinical lab test paid under the Clinical Lab Fee Schedule; 
  • Collected by a trained technician from a Medicare beneficiary who is homebound or is a non-hospital inpatient, but only when no qualified personnel are available at the facility to collect the specimen; and
  • Of the following type — a blood specimen collection through venipuncture or a urine sample collected by catheterization
• The phrase “trained technician” refers to those staff providing specimen collection services. It does not mandate certain educational requirements and, for the purposes of the specimen collection provisions, the term includes a phlebotomist.
• A specimen collection fee is allowed in two circumstances:
  • Drawing a blood sample through venipuncture (i.e., inserting into a vein a needle with syringe or vacutainer to draw the specimen); or
  • Collecting a urine sample by catheterization 

Independent Laboratory

• A specimen collection fee may be allowed when it is medically necessary for a trained technician to draw a specimen from either a nursing home patient, a non-hospital inpatient, or homebound patient
  • The trained technician must personally draw the specimen (e.g., venipuncture or urine sample by catheterization)
• Medicare does not allow a specimen collection fee to the visiting technician if a patient in a facility is not confined to the facility or the facility has personnel on duty qualified to perform the specimen collection
• A patient need not be bedridden to be homebound
• When a laboratory obtains the specimen collection in the home place of service (POS 12 or 14) or nursing facility (POS 13, 31, 32, 33 or 54) it may receive payment for both the draw and for the associated travel to obtain the specimen(s) for testing
• When an independent laboratory obtains a specimen for a nursing home patient, a non-hospital inpatient, or homebound 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 to be homebound if he or she has a condition due to an illness or injury that restricts his or 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. (See Publication 100-02, the Medicare Benefit Policy Manual Chapters 7 and 15, for more information regarding medically necessary laboratory services to a homebound or institutional patient.) 

Travel Allowance

• Travel allowance may be made in addition to a paid, medically necessary specimen collection fee when the specimen is collected from a nursing home patient, a nonhospital inpatient 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 travel allowance will not be paid if a trained technician merely performs a messenger service to pick up a specimen drawn by other technicians
• The allowance is intended to cover the transportation and personnel expenses for trained personnel to travel to the location of an individual to collect the sample 
• Eligible miles by a trained technician’s travel for specimen collection from Medicare beneficiaries may begin at a laboratory or at a location other than the laboratory. Therefore, eligible miles begin at the laboratory or the starting point of the trained technician’s travel for specimen collection. 
• Additionally, a trained technician’s travel for specimen collection from Medicare beneficiaries may end at a laboratory or at a location other than the laboratory. Therefore, eligible miles end at the laboratory or the ending point of the trained technician’s travel for specimen collection. 
• Eligible miles do not include miles traveled for any purpose unrelated to specimen collection, such as collecting specimens from non-Medicare beneficiaries or for personal reasons. Therefore, any miles traveled to a location where no specimens are collected, such as to the location of a non-Medicare beneficiary for specimen collection, to a Medicare beneficiary where no specimen collection occurs, or for personal purposes, are excluded from the calculation of eligible miles. 
• CMS has made permanent the option for laboratories to maintain electronic documentation of miles traveled for the purposes of covering the transportation and personnel expenses for trained technicians to travel to the location of an individual to collect a specimen sample. This option for laboratories to maintain electronic documentation applies to specimen collection for any clinical laboratory test. Laboratories may use electronic and/or other documentation in order to demonstrate miles traveled for the purposes of specimen collection. Laboratories need to be able to produce electronic documentation in a form and manner that can be shared with MACs and should continue to consult with their local MACs regarding the format and process for submission of this information if necessary. 

HCPCS Code P9603 — When/How to Use This Code

• The per-mile travel allowance basis applies in two circumstances:
  • The round trip travel to one location is greater than 20 eligible miles for specimen collection from one or more beneficiaries; or
  • When travel is to more than one location, regardless of the number of miles traveled
• Use HCPCS code P9603 to receive payment for the per mile travel allowance amount, prorated by the number of beneficiaries for whom a specimen collection fee is paid
• See Publication 100-04, Chapter 16, Section 60.2 (PDF)for the per-mile travel allowance calculation
• The quantity billed for HCPCS code P9603 must reflect the actual number of miles traveled

HCPCS Code P9604 — When/How to Use This Code

• The flat rate travel allowance basis applies when the trained technician travels 20 eligible miles or less to and from one location for specimen collection from one or more Medicare beneficiaries
• Use HCPCS code P9604 to receive payment for the flat rate travel allowance amount, prorated by the number of beneficiaries for whom a specimen collection fee is paid 
• The quantity billed must be one
• See Publication 100-04, Chapter 16, Section 60.2 (PDF) for the flat rate travel allowance calculation

HCPCS Modifier LR

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

References

• CMS Publication 100-02, Chapters 7, 15, and 16, Section 180
• CMS Publication 100-04, Chapter 16, Section 50.5 (PDF)
• CMS Publication 100-04, Chapter 16, Section 60 (PDF)