CurrentEmpire BluecrossPolicy C-21010

Laboratory and Venipuncture Services Professional and Facility

Defines Empire BlueCross reimbursement rules for professional and facility laboratory and venipuncture services, including bundling, modifier use, and when specimen-collection and handling codes are eligible or denied; applies to commercial members and providers submitting claims to the Health Plan.

Policy Summary

PayerEmpire Bluecross

PolicyLaboratory and Venipuncture Services Professional and Facility

Policy CodePolicy C-21010

Change TypeClarified code-specific reimbursement rulescoverage language expanded

Effective DateAug 6, 2024

Next Review Date

Key ActionProviders must submit claims with industry-standard CPT/HCPCS/revenue codes and include a valid CLIA certificate ID on CMS-1500 for clinical laboratory services.

SourceLink

POLICY UPDATE CHANGES

Added clarifying language to Professional Section III and to the code list for codes 36591 and 36592.

Effective 08/06/2024 the policy expanded coverage language and was approved.

1 per member/provider/datevenipuncture frequency limit

36591/36592separate reimbursement conditional

99000/99001/P9603+not separately reimbursed

CLIA IDdocumentation required

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Coverage Criteria for Laboratory and Venipuncture Services

Reimbursement and denial rules for professional and outpatient facility claims, bundling of component tests into panels, specimen collection and handling codes, modifier use, frequency limits, and documentation requirements.

When the Health Plan receives a claim for two or more individual laboratory procedure codes that are part of a comprehensive blood panel or CBC, the claim-editing system will bundle those separate tests into the appropriate comprehensive CPT code; the comprehensive panel/CBC code will be eligible for reimbursement and the individually reported component codes will be denied; modifiers will not override this edit.

Providers must submit a valid CLIA certificate identification number on the CMS-1500 for reimbursement of clinical laboratory services; if the required information is not submitted, the claim will be rejected or denied.

ALL of the following

Professional setting
- Routine venipuncture/capillary collection codes (CPT 36415, 36416 and HCPCS S9529) are eligible for separate reimbursement when reported by a professional provider with an E/M and/or a laboratory service; frequency is limited to once per member, per provider, per date of service (applies to any combination of these codes); modifiers will not override the frequency edit.
- Collection of blood specimen from access device or catheter (CPT 36591, 36592) reported by a professional provider is eligible for separate reimbursement only when reported with a laboratory service; if reported with an E/M, the E/M will not be reimbursed separately.
- Specimen collection for SARS-CoV-2 (C9803) reported by the same professional provider performing the laboratory analysis will be denied as obtaining the sample is integral to the lab analysis.
Outpatient facility setting
- Routine venipuncture/capillary collection codes (CPT 36415, 36416 and HCPCS S9529) reported by an outpatient facility will be denied for separate reimbursement and included in the facility payment; modifiers will not override this edit.
- Collection of blood specimen from access device or catheter (CPT 36591, 36592) reported by an outpatient facility will be denied for separate reimbursement and included in the facility payment; modifiers will not override this edit.
- Specimen collection for SARS-CoV-2 (C9803) reported by an outpatient facility will be denied for separate reimbursement and included in the facility payment.

Handling, conveyance, and travel allowance codes for specimen pickup (99000, 99001, P9603, P9604, H0048) are considered included in provider management of the patient and are not eligible for separate reimbursement.

Modifier TC (technical) and 26 (professional) must be reported correctly per CPT reporting guidelines; global procedures performed by the same professional are eligible only when billed appropriately (modifiers will not override bundling edits or frequency edits).

Key Codes, Frequency Limits, and Coding Rules

Covered CPT CodesCPTCovered

80047	Comprehensive metabolic panel (CMP) — includes specified constituent tests; report as panel when all/majority of constituent tests performed
80053	Comprehensive metabolic panel — different panel definition; do not report in conjunction with 80047 if tests overlap; report the panel that incorporates the greater number of tests
36415	Collection of venous blood by venipuncture
36416	Collection of capillary blood specimen

Covered HCPCS CodesHCPCSCovered

S9529	Routine venipuncture, professional service
G0471	Collection of venous blood by venipuncture from an individual in a SNF or on behalf of an HHA when performed by laboratory personnel

Billing, Authorization, and Documentation Requirements

Billing Rule

Submit industry-standard codes and CLIA ID on CMS-1500

Providers must submit claims using industry-standard CPT, HCPCS, or revenue codes and include a valid CLIA certificate identification number on the CMS-1500 when billing clinical laboratory services. Failure to follow proper billing/submission guidelines or to provide required CLIA information may result in claim rejection, denial, or recoupment.

Use Current Procedure Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and/or revenue codes on all claim submissions.
Enter a valid Clinical Laboratory Improvement Amendments (CLIA) certificate ID on the CMS-1500 for clinical laboratory service reimbursement.
Noncompliance with coding/billing guidelines or missing CLIA information may lead to claim rejection, denial, or recovery/recoupment of payments.

Definitions and Modifier Rules

inv-05: Venipuncture — definition of venipuncture as the process of withdrawing blood for analysis or testing.

DefinitionVenipuncture is the process of withdrawing a sample of blood for the purpose of analysis or testing.

ContextIncludes routine venipuncture and capillary blood collection procedures (e.g., CPT 36415, 36416; HCPCS S9529) as addressed in the policy.

DocumentationClaims for venipuncture-related clinical laboratory services require submission of a valid CLIA certificate identification number on CMS-1500 for reimbursement.

inv-06: Modifiers (TC/26) — description of Technical (TC) and Professional (26) component modifiers and billing expectations.

Modifier meaningsTC indicates the technical component; 26 indicates the professional component of a laboratory procedure.

Billing expectation