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Venipuncture

As of Tuesday, April 1, we’ll align our payment policy for venipuncture with current Centers for Medicare and Medicaid Services (CMS) guidelines across all our plans. Specifically, we’ll identify claims where lab and venipuncture services are rendered by the same provider to the same patient on the same date of service and only reimburse for the lab codes.

The procedure code we’ll evaluate is CPT 36415 — routine venipunctures. When 36415 is billed in conjunction with lab services and the services are rendered by the same provider to the same patient on the same date of service, 36415 will not be separately reimbursed.  Reimbursement will only be for the lab services.

CMS guidelines recommend treating venipuncture codes as incidental and non-reimbursable when performed in the same encounter as a lab service in the office or outpatient setting. CMS does allow for separate reimbursement when performed in non-hospital inpatient, home, or independent lab settings.

Duplication of overlapping services

As of Thursday, May 1, we’ll align our approach to payment for evaluation and management (E&M) codes billed with modifier 25 and rendered in the same visit as a preventive medicine service with market-standard policies. E&M codes billed with modifier 25 during a preventive medicine visit will be reimbursed at 50%, as those costs are already considered in the reimbursement of the preventive service. Example procedure codes billed in this manner that may be impacted are listed below. This change will apply across all our plans.

Relevant E&M procedure codes that may be subject to this policy change include, but are not limited to:

  • 99202-99215
  • 99241-99245
  • G0245
  • G0246
  • G0463
  • S0285
  • S0610
  • S0612

Relevant preventive procedure codes that may be subject to this policy change include, but are not limited to: 

  • 99381-99397
  • G0402
  • G0438
  • G0439

The code list above is not comprehensive and is subject to change based on periodic updates by CMS or the American Medical Association (AMA).


Our commitment to coding accuracy

Helping you with billing accuracy and enhancing the integrity of GHP claims processing are always top of mind. That’s why we continue to rely on internal and external payment accuracy and claim editing solutions.

Whether it’s blood draws for lab testing, E&M services related to a preventive care visit, or any other type of patient service, making sure you bill correctly is always the best way to reduce denials, so your claims are adjudicated in a timely, accurate manner.

 

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