Laboratory and Venipuncture Services - Professional and Facility
Defines Anthem's reimbursement rules for professional and facility claims for laboratory tests, specimen collection (venipuncture/capillary), handling/transport allowances, and related modifiers; applies to Anthem commercial plans and providers submitting claims unless superseded by contracts or mandates.
Codes 99000 - 99001 and H0048 were removed from the Bundled Services and Supplies professional policy and added to this consolidated Laboratory and Venipuncture Services - Professional and Facility policy.
Coverage Criteria
Laboratory panel editing — Panel bundling and reimbursement limits
Covered when ALL of the following apply:
ALL of the following
- Laboratory combination editing: When the plan receives claims for individual laboratory procedure codes that are components of a recognized panel or multiple-component test, the claim-editing system will bundle those separate tests into the appropriate comprehensive CPT® panel code per CPT® reporting guidelines. Modifiers will not override this edit.
The plan will add the comprehensive panel code to the claim and reimburse only the comprehensive code; individually reported component codes will be denied.
- CPT® panel overlap rule: Do not report two or more panel codes that include any of the same constituent tests from the same patient collection. If tests overlap panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report remaining tests using individual test codes.
- Reimbursement limit: Total reimbursement for individually billed laboratory codes that are part of a comprehensive blood panel/CBC will not exceed the allowance for the comprehensive blood panel/CBC code.
- CLIA: The plan does not require submission of a valid CLIA certificate identification number or modifier QW for CLIA‑waived tests for reimbursement of clinical laboratory services reported on a CMS‑1500 form.
Modifier requirements for professional/component reporting
Laboratory professional/component modifier reporting rules:
ALL of the following
- TC/26 modifiers: Laboratory procedure codes must be billed with the correct technical (TC) or professional (26) modifier when applicable to receive reimbursement. When a professional provider performs both technical and professional components and bills the global procedure, the global procedure is eligible for reimbursement only if billed without TC or 26 and without a facility Place of Service.
- Laboratory-specific modifiers (90, 91, 92): Conditions of reimbursement for modifiers 90, 91, and 92 follow the Related Coding section and CPT® guidelines; apply these modifiers only per CPT® and plan guidance.
- Modifiers will not override bundling edits: Modifiers do not override the plan's laboratory panel bundling or venipuncture edits unless specifically stated otherwise in Related Coding guidance.
Venipuncture and access device collection reimbursement rules
Venipuncture and access device collection reimbursement rules:
ALL of the following
- Routine venipuncture/capillary collection (professional): HCPCS S9529 and CPT® 36416 are eligible for separate reimbursement when reported with an E&M and/or a laboratory service. Frequency limit: once per member, per provider, per date of service unless clinically necessary; the limit applies to any combination of these codes on the same date of service by the same provider.
- Routine venipuncture with E&M: CPT® 36415 reported with E&M office visit codes 99202-99205 or 99211-99215 is considered included in the E&M reimbursement and will not be reimbursed separately. Modifiers will not override this edit.
- Outpatient facility reporting (facility): Routine venipuncture CPT® codes 36400, 36405, 36406, 36410, 36415, and 36416 reported by an outpatient facility will be denied as separate claims and are included in the facility payment. Collection from access device CPT® codes 36591 and 36592 reported by an outpatient facility will be denied and included in the facility payment. Modifiers will not override these facility edits.
Handling, conveyance, and travel allowances
Handling, conveyance, and travel allowances:
ALL of the following
- Handling/conveyance/travel included in patient management: The plan considers specimen pickup, handling, conveyance, and travel allowances to be part of the provider's management of the patient and not separately reimbursable.
- Facility note: For outpatient facility claims, handling/collection and venipuncture/collection are included in the facility payment and are not separately reimbursed; facility providers are subject to the facility‑specific denials noted above.
Coding and Billing Codes
| 36415 | Routine venipuncture, by venipuncture |
| 36416 | Collection of capillary blood specimen (e.g., finger, heel), microcollection techniques |
| 36400 | Venipuncture, needle or syringe |
| 36405 | Venipuncture with insertion of catheter, without blood collection |
| 36406 | Venipuncture with insertion of catheter, with blood collection |
| 36410 | Venipuncture for collection of specimen(s) from indwelling catheter, with catheter replacement |
| 36415 | Routine venipuncture — included in E&M office visit reimbursement when billed with codes 99202-99205, 99211-99215 (not separately reimbursed in that context); payable separately with laboratory service when not bundled into E&M |
| 36416 | Capillary blood collection — eligible for separate reimbursement when reported with an E&M and/or a laboratory service; frequency limit: once per member, per provider, per date of service |
| 36400 | Venipuncture, needle or syringe — when reported by an outpatient facility: denied (included in facility payment) |
| 36405 | Venipuncture with insertion of catheter, without blood collection — when reported by an outpatient facility: denied (included in facility payment) |
| 36406 | Venipuncture with insertion of catheter, with blood collection — when reported by an outpatient facility: denied (included in facility payment) |
| 36410 | Venipuncture for collection from indwelling catheter — when reported by an outpatient facility: denied (included in facility payment) |
Provider Actions and Expectations
Authorization, medical necessity, and claim submission requirements
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence. Providers must follow proper billing and submission guidelines using industry-standard CPT, HCPCS, and/or revenue codes, and ensure codes billed are fully supported in the medical record or office notes. Failure to follow coding/billing guidelines may result in claim rejection or denial, and Anthem may recover/recoup claim payment.
- Use industry-standard, compliant codes (CPT, HCPCS, revenue codes) on all claim submissions.
- Ensure billed services are fully supported in the medical record and/or office notes.
- Be aware that noncompliance with coding/billing guidelines may lead to claim rejection/denial or recovery/recoupment of payment.
- Policy provisions may be superseded by provider, state, federal, or CMS mandates—verify applicability.
Definitions
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