CurrentEmblemHealthPolicy RP2O220018

Laboratory/Venipuncture (Commercial, Medicare & Medicaid)

Governs EmblemHealth reimbursement rules for clinical laboratory services, specimen collection/handling, and related coding for Commercial, Medicare and Medicaid products; affects providers submitting CMS-1500 claims.

Policy Summary

PayerEmblemHealth

PolicyLaboratory/Venipuncture (Commercial, Medicare & Medicaid)

Policy CodePolicy RP2O220018

Change TypeMultiple revisions (coding updates, in-office test lists, CLIA reporting)

Effective DateCommercial/Medicare: 2020-07-01; Medicaid: 2022-07-01

Next Review Date

Key ActionInclude a valid CLIA Certificate ID and ordering provider name, NPI and TIN on diagnostic lab claims or the claim may be pended or denied.

SourceLink

POLICY UPDATE CHANGES

Updated policy to align with CMS regarding reimbursement for 85060, effective 8/13/2023; removed CPT Code 85060 from In-Office Laboratory table.

Updated to include Reimbursement Guidelines for 87631-87633 with guidelines aligning with CMS effective 7/14/2023 and added 87631 to In-Office Testing table.

Updated policy to indicate that 87428 is allowed In-Office for Commercial and Medicare, effective 11/10/2020.

Updated policy to include reporting CLIA ID Number on a claim form.

Added certain CPT codes (83001, 83002, 84144) to In-Office Laboratory table for specified specialties.

Added 87389 to In-Office Laboratory table for Medicare plans only; applicable CPT code must be billed for Commercial and Medicaid plans.

Updated policy title to include Medicare and updated In-Office Testing Table to include effective dates for clarification.

Updated policy to align with Medicaid Fee Schedule effective 7/01/2022 and reformatted/reorganized policy.

1venipuncture reimbursed per patient per date

387631 targets reimbursed

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87632/87633 reimbursement

1collection fee allowed per specimen

1duplicate billing favored to performer

not reimbursedmodifier 90 stance

Coverage and Reimbursement Criteria

Laboratory reimbursement criteria

Reimbursement rules and bundling/unbundling criteria for laboratory services and related codes.

Individual laboratory component codes that comprise a laboratory panel will be combined and reimbursed as the comprehensive panel code; panels split among multiple laboratories or settings (unbundling) are not reimbursable.

Specimen collection fees are not reimbursed when billed by the same provider who performs the laboratory services; only one collection fee is allowed per specimen type per patient encounter and a provider who did not extract the specimen will not be reimbursed for collection.

Venipuncture/capillary collection codes 36415 and 36416 are reimbursed once per patient per date of service when reported by the same individual provider; when 36416 is submitted with 36415, only 36415 is eligible. No modifier overrides this bundling. Codes 36591 and 36592 are bundled similarly; when both are submitted only 36592 is eligible. S9529 is considered non-reimbursable and G0471 is reimbursable only when specimen collection is from a skilled nursing facility or on behalf of a home health agency.

CPT codes 99000 and 99001 and HCPCS codes H0048 and S3600 (handling/conveyance) are not separately reimbursed when submitted with another code or as the only code on the same date of service.

When CPT/HCPCS descriptions specify a unit measure (eg, ‘per’ or ‘each’), bill multiple services as multiple units on one line; otherwise report one unit for all services.

Modifier rules (select as applicable)

When NPFS indicates modifier 26/TC applies and a professional provider reports a procedure with a facility place of service, the procedure must be reported with modifier 26 or it will not be eligible for reimbursement; when both components are performed by the same provider report the global code without 26/TC.
EmblemHealth will reimburse laboratory services reported with modifier 59 or the selective X{EPSU} modifiers for different species/strains or specimens from distinctly separate anatomic sites when appropriate; CPT guidance regarding 59 vs X modifiers applies.

Consistent with CMS guidance for respiratory virus multiplex NAATs, EmblemHealth will consider reimbursement for only CPT 87631 (3–5 targets); CPT 87632 and 87633 (6+ targets) are not reimbursed and testing with 5+ targets billed as 87632/87633 is considered not medically necessary.

When multiple providers submit identical laboratory codes for the same patient and date of service, EmblemHealth will reimburse the provider who actually performed the test; when identical codes are submitted by a pathologist and another physician the pathologist’s service is reimbursable over the other physician.

CPT codes 82947 and 82948 are treated as equivalent codes for duplicate charge determination in glucose testing contexts.

Certain services (for example 36591/36592 and listed handling codes) will not be separately reimbursed when performed by a nurse or other ancillary staff per the policy guidelines.

Laboratory reimbursement and billing criteria

EmblemHealth reimbursement and billing criteria for laboratory services:

Respiratory virus nucleic acid amplification tests (NAAT) — EmblemHealth will consider reimbursement only for CPT 87631 (multiplex 3–5 targets). CPT 87632 (6–11 targets) and CPT 87633 (12–25 targets) will not be reimbursed; testing with 5+ targets billed as 87632/87633 is considered not medically necessary.

A valid CLIA Certificate Identification number is required on claims for reimbursement of clinical laboratory services; claims missing the CLIA ID, containing an invalid CLIA ID, or lacking complete servicing provider demographic information will be considered incomplete and may be rejected or denied. Claims for services where the lab certification level does not support the billed service code will result in claim line edits and nonpayment.

In‑office testing — EmblemHealth provides a defined list of laboratory tests that network physicians may perform and be reimbursed for when done in-office; all other tests should be sent to Quest Diagnostics or another participating laboratory and will be reimbursed according to contracted fee schedules.

Modifier 90 (reference/outside laboratory) indicates pass‑through billing for a service not performed by the billing provider; EmblemHealth will not reimburse modifier 90 and reimburses only providers who perform the procedures.

Coverage and billing rules

Key coverage and billing criteria from this excerpt:

Do not append modifier 90 for reimbursement — EmblemHealth does not reimburse modifier 90 (reference/outside laboratory).

Modifier 91 may be used for repeat laboratory services performed by a different individual in the same group on the same day when clinically appropriate per CMS/CPT guidance.

Certain CPT/HCPCS codes noted in the policy tables are acceptable for Medicare plans only; for Commercial and Medicaid plans submit the applicable CPT code as specified.

Claims for diagnostic laboratory services must include the ordering physician's name, NPI, and TIN; claims may be pended or denied if this information is missing.

This policy has undergone multiple revisions to align with CMS guidance and Medicaid fee schedules; recent revisions include changes related to in‑office testing allowances and reimbursement guidance for respiratory NAAT CPTs (87631–87633).

Codes, Modifiers, and Reimbursement Limits

Laboratory and specimen collection codesmixed

82947	Glucose; quantitative, blood (except reagent strip)
82948	Glucose; blood, reagent strip
36415	Venous blood collection by venipuncture
36416	Capillary blood specimen collection
36591	Collection from completely implantable venous access device
36592	Collection from established catheter
99000	Handling and/or conveyance of specimen (non-reimbursable)
99001	Handling and/or conveyance of specimen (non-reimbursable)
H0048	Collection and handling only, specimens other than blood (non-reimbursable)
S9529	Routine venipuncture for collection of specimen(s) (non-reimbursable)

1–10 of 15

1/2

Respiratory virus multiplex NAAT CPTsCPT

87631	Respiratory virus NAAT, multiplex, 3-5 targets (covered)
87632	Respiratory virus NAAT, multiplex, 6-11 targets (not reimbursed)
87633	Respiratory virus NAAT, multiplex, 12-25 targets (not reimbursed)

Laboratory modifiersModifier

90	Modifier 90 (reference/outside laboratory) — EmblemHealth does not reimburse
91	Modifier 91 (repeat lab by different individual in same group) — appropriate in specific circumstances
92	Modifier 92 (alternative laboratory platform testing) — for single-use transportable devices
QW	CLIA waived test modifier

Laboratory/Venipuncture CPT codes listedCPT

89321
89322
89330
89335
89337
89342
89352
89353
89354
89356

inv-08: max_multiplex_targets_reimbursable

Reimbursable CPT87631 — respiratory virus multiplex NAAT with 3–5 targets is considered for reimbursement

Not reimbursed87632 and 87633 — tests with 6+ targets are not reimbursed (considered not medically necessary)

Policy alignmentRule consistent with CMS guidance cited in policy

inv-09: Maximum targets for reimbursed respiratory multiplex CPTs

Allowed respiratory multiplexOnly CPT 87631 (3–5 targets) will be considered for reimbursement

Disallowed billing

Provider Billing Requirements and Actions

Documentation Required

Billing and CLIA requirement

You may only bill for laboratory services that you or your staff actually perform; pass-through billing is not permitted. You must have the applicable CLIA certification to bill for and be reimbursed for laboratory services.

Do not bill EmblemHealth for tests your practice is not certified to perform.
Validate CLIA requirements on CMS/CLIA resources when unsure of test complexity.

Billing Rule

Duplicate billing resolution

When identical laboratory services are billed for the same patient on the same date by multiple providers, EmblemHealth will reimburse the provider or entity that actually performed the test; if a pathologist and another physician submit identical codes on the same date, only the pathologist's service is reimbursable.

Definitions and Regulatory Context

inv-16: CLIA

DefinitionCLIA — Clinical Laboratory Improvement Amendments; federal certification required for most labs performing tests on humans

Reimbursement requirementA valid CLIA certificate is required to bill and to be reimbursed for laboratory services

Regulatory scopeCLIA covers laboratory certification, proficiency testing, and applies to physician office, independent, and other labs

inv-17: POS

DefinitionPOS — Place of Service code indicating where the laboratory service was performed

Use for reimbursementEmblemHealth uses CMS Place of Service codes to determine if laboratory services are reimbursable

Policy Revision History

2023-05-08revision

Updated policy to indicate that CPT 87428 is allowed in-office for Commercial and Medicare (effective 2020-11-10).

2023-03-30revision

Aligned policy with CMS regarding reimbursement for CPT 85060, effective 2023-08-13; removed CPT 85060 from the In-Office Laboratory table.

2023-02-14revision

Added reporting requirement for CLIA Certificate ID on claim forms and added CPTs 83001, 83002, and 84144 to the In-Office Laboratory table for select specialties.

Policy Summary

PayerEmblemHealth

PolicyLaboratory/Venipuncture (Commercial, Medicare & Medicaid)

Policy CodePolicy RP2O220018

Change TypeMultiple revisions (coding updates, in-office test lists, CLIA reporting)

Effective DateCommercial/Medicare: 2020-07-01; Medicaid: 2022-07-01

Next Review Date

Key ActionInclude a valid CLIA Certificate ID and ordering provider name, NPI and TIN on diagnostic lab claims or the claim may be pended or denied.

SourceLink

On This Page

Other modifier guidance

Modifier 91 is appropriate for same‑day repeat testing performed by a different individual in the same group under the same TIN when clinically necessary (eg, repeated blood tests at different intervals).
Modifier 92 identifies alternative laboratory platform testing for transportable/single‑use devices when applicable. QW denotes CLIA‑waived tests.

Note: some listed CPT/HCPCS codes in the policy tables are acceptable for Medicare Plans only; providers should submit the appropriate CPT code for Commercial and Medicaid plans as indicated in the policy tables.

Tests performed with 6+ targets billed as CPT 87632 or 87633 will not be reimbursed

Clinical rationaleAny testing with 5+ targets (pathogens) is considered not medically necessary when reported with 87632/87633

inv-10: Medicare-only codes note

Medicare-only acceptabilityCertain listed CPT/HCPCS codes are acceptable for Medicare Plans only

Commercial/Medicaid requirementSubmit the appropriate CPT code for Commercial and Medicaid plans (do not rely on Medicare-only codes)

Modifier contextSee modifier guidance (e.g., 90, 91, 92) for appropriate reporting when using Medicare-only codes

Ensure claims reflect the performing provider to avoid denial or payment to another party.

Prior Authorization

Prior authorization / billing actions and requirements for respiratory NAATs

EmblemHealth will consider reimbursement for respiratory viral nucleic acid detection multiplex CPT 87631 only; CPTs 87632 and 87633 will not be reimbursed and tests with 5+ targets are considered not medically necessary. Include a valid CLIA Certificate ID on claims for laboratory tests or the claim may be rejected or denied.

Bill respiratory multiplex NAATs using CPT 87631 when the test covers 3–5 targets; do not submit 87632 or 87633 for reimbursement.
Report the billing laboratory's CLIA Certificate Identification number on claims (Loop 2300, REF02) to meet reimbursement requirements.

Denial Risk

Ordering provider claim requirements

List the ordering physician's name, NPI and TIN on diagnostic claims (labs and radiology); failure to include this information may result in the claim being pended or denied.

Verify ordering provider demographics are present on CMS-1500 claims to avoid delays.

Billing Rule

Modifier 90 reimbursement rule

Do not append modifier 90 for reimbursement; EmblemHealth does not reimburse modifier 90 (reference/outside laboratory).

Do not bill procedures with modifier 90 expecting payment if the billing provider did not perform the service.

Claim-level impactCorrect POS supports appropriate payment and adjudication of lab claims

inv-18: CLIA Certificate Identification number required for reimbursement and must be reported on claims (Loop 2300, REF02) for CLIA-covered laboratory tests.

Claim reporting locationReport the billing laboratory's CLIA ID in Loop 2300, REF02 (REF01–X4) for all CLIA-covered lab tests

Requirement consequenceClaims missing a valid CLIA ID or with invalid CLIA ID will be considered incomplete and may be rejected or denied

ApplicabilityApplies to CMS-1500 and electronic equivalents for CLIA-covered laboratory tests

inv-19: Descriptions of respiratory virus nucleic acid detection CPTs and target counts (87631 = 3-5 targets; 87632 = 6-11 targets; 87633 = 12-25 targets).

87631 descriptionInfectious agent detection by nucleic acid; respiratory virus multiplex — includes multiplex RT and amplified probe techniques; 3–5 targets

87632 descriptionRespiratory virus NAAT multiplex; 6–11 targets

87633 descriptionRespiratory virus NAAT multiplex; 12–25 targets

inv-20: CLIA — Federal program regulating laboratory testing on humans; covers labs and sets certification/proficiency testing requirements.

Program overviewCLIA is the federal program (Clinical Laboratory Improvement Amendments) that regulates laboratory testing on humans

Certification requirementLaboratories must meet applicable federal CLIA requirements and hold a current CLIA certificate to perform and bill tests

ScopeCLIA governs certification, proficiency testing, and standards for approximately 251,000 laboratory entities

inv-21: CLIA Waived Test — Simple tests with insignificant risk of erroneous result as defined by CLIA.

DefinitionCLIA Waived Test — tests categorized by CLIA as simple with an insignificant risk of erroneous result

ModifierQW denotes CLIA waived tests in modifier guidance

ImplicationWaived tests have simplified regulatory requirements compared with higher complexity tests

inv-22: Venipuncture — Definition and common usage.

DefinitionVenipuncture — blood collection by inserting a needle into the cubital vein of the anterior forearm (common site)

Common usageUsed to collect blood specimens for diagnostic laboratory analysis

Related CPTsCodes such as 36415 (venous blood collection) are referenced in policy for reimbursement rules

inv-23: Laboratory types — Independent/Reference/Referring Laboratory distinctions and modifier guidance.

Independent vs Reference vs ReferringIndependent and Reference labs perform testing and must append modifier 90 to reported services per definitions (though EmblemHealth does not reimburse modifier 90)

Referring LaboratoryA referring lab sends a specimen to another lab for testing and must append modifier 90 when reporting services

Physician office labPhysician office laboratories perform tests for their practice and have distinct reporting requirements

inv-24: Duplicate Laboratory Service — Identical or equivalent bundled laboratory component codes submitted for same patient/same date on separate claims.

DefinitionDuplicate Laboratory Service — identical or equivalent bundled laboratory component codes submitted for same patient on same date on separate claim lines or different claims

Policy effectSuch duplicate submissions are evaluated as duplicate laboratory services and may be denied or adjusted

Relation to panelsIndividual component codes that comprise a panel are combined and reimbursed as the panel rather than separately when submitted

2023-02-?revision

Updated to include reimbursement guidelines for CPTs 87631-87633 aligning with CMS (87631 reimbursable; 87632/87633 not reimbursed) and added 87631 to the In-Office Testing table (effective 2023-07-14 per CMS alignment).

2022-10revision

Added CPT 87389 to the In-Office Laboratory table for Medicare plans only; Commercial and Medicaid must bill the applicable CPT code.

2022-05revision

Updated policy title to include Medicare and updated the In-Office Testing Table to include effective dates for clarification.

2022-01-21revisionLatest

Aligned policy with the Medicaid Fee Schedule effective 2022-07-01; reformatted and reorganized the policy and transferred content to a new template with a new reimbursement policy number.