by Jared Staheli
July 10th, 2015
Medicare allows separate charges made by laboratories for drawing or collecting specimens whether or not the specimens are referred to hospitals or independent laboratories. The laboratory does not bill for routine handling charges where a specimen is referred by one laboratory to another.
Medicare allows payment for a specimen collection fee when it is medically necessary for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient. Payment for the specimen collection fee is made based on the clinical laboratory fee schedule. The 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 (a) not confined to the facility, or (b) the facility has personnel on duty qualified to perform the specimen collection. Medical necessity for such services exists, for example, where a laboratory technician draws a blood specimen from a homebound or an institutionalized patient. A patient need not be bedridden to be homebound. However, where the specimen is a type that would require only the services of a messenger and would not require the skills of a laboratory technician, e.g., urine or sputum, a specimen pickup service would not be considered medically necessary. (See Chapters 7 and 15 of the Medicare Benefit Policy Manual for a discussion of “homebound” and a more complete definition of a medically necessary laboratory service to a homebound or an institutional patient.)
In addition to the usual information required on claim forms (including the name of the prescribing physician), all independent laboratory claims for such specimen drawing or EKG services prescribed by a physician should be appropriately annotated, e.g., “patient confined to home,” “patient homebound,” or “patient in nursing home, no qualified person on duty to draw specimen.” Carriers must assure the validity of the annotation through scientific claims samples as well as through regular bill review techniques. (This could be done by use of the information in carrier files, and where necessary, contact with the prescribing physician.)
If a physician requests an independent laboratory to obtain specimens in situations which do not meet, or without regard to whether they meet, the medical necessity criteria in Chapter 15 of the Medicare Benefit Policy Manual, an educational contact with the prescribing physician is warranted and, where necessary, corroborating documentation should be obtained on claims until the carrier is assured that the physician prescribes such services only when the criteria are met.
The specimen collection fee is paid based on the location of the independent laboratory where the test is performed and is billed in conjunction with a covered laboratory test.