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C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 1 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Commercial Reimbursement Policy
Subject: Laboratory and Venipuncture Services – Professional and Facility
Policy Number: C-21010
Policy Section: Laboratory
Last Approval Date: 10/25/2023
Effective Date: 06/01/2024
Disclaimer
These reimbursement policies serve as a guide to assist you in accurate claims
submissions and to outline the basis for reimbursement if the service is covered by an
Anthem Blue Cross and Blue Shield (Anthem) member’s benefit plan. The
determination that a service, procedure, item, etc. is covered under a member's benefit
plan is not a determination that you will be reimbursed. Services must meet
authorization and medical necessity guidelines appropriate to the procedure and
diagnosis, as well as to the member’s state of residence.
You must follow proper billing and submission guidelines. You are required to use
industry standard, compliant codes on all claim submissions. Services should be billed
with Current Procedure Terminology (CPT) codes, Healthcare Common Procedure
Coding System (HCPCS) codes and/or revenue codes. These codes denote the
services and/or procedures performed and when billed, must be fully supported in the
medical record and/or office notes. Unless otherwise noted within the policy, our
reimbursement policies apply to both participating and non-participating professional
providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not
followed, Anthem may:
• Reject or deny the claim.
• Recover and/or recoup claim payment.
These reimbursement policies may be superseded by mandates in provider, state,
federal, or Centers for Medicare & Medicaid Services (CMS) contracts and/or
requirements. We strive to minimize delays in policy implementation. If there is a delay,
we reserve the right to recoup and/or recover claims payment to the effective date, in
accordance with the policy. We reserve the right to review and revise these policies
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C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 2 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
when necessary. When there is an update, we will publish the most current policy to the
website.
Policy
The Health Plan identifies conditions for reimbursement for professional and facility
providers of laboratory and venipuncture services, which will be applied to submitted
claims unless provider, state, or federal contracts and/or mandates indicate otherwise.
Professional:
I. Laboratory Combination Editing for Component Codes
i. When the Health Plan receives a claim for all of the individual laboratory
procedure codes that are part of a blood panel grouping (or other multiple-
component laboratory tests) the Health Plan’s claim-editing system will bundle
those separate tests together into the appropriate comprehensive CPT® code
listed in the “Related Coding” section below. This claim editing is based on
CPT® reporting guidelines. Modifiers will not override this edit.
ii. The Health Plan follows CPT® reporting guidelines, which state: “Do not report
two or more panel codes that include any of the same constituent tests
performed from the same patient collection. If a group of tests overlaps two or
more panels, report the panel that incorporates the greater number of tests to
fulfill the code definition and report the remaining tests using individual test
codes (e.g., do not report 80047 in conjunction with 80053).”
iii. The Health Plan’s total reimbursement for individual laboratory codes that are
part of a comprehensive blood panel/CBC code will not exceed the allowance
for such comprehensive blood panel/CBC code.
• When the Health Plan receives a claim for two or more of the individual
laboratory procedures codes that are part of a comprehensive blood
panel/CBC code the Health Plan’s claim-editing system will bundle those
separate tests together into the appropriate comprehensive blood
panel/CBC code. The comprehensive blood panel/CBC code will be
added to the claim regardless of whether the provider bills all of the
individual codes that make up the comprehensive blood panel/CBC
code.
• The laboratory comprehensive blood panel/CBC code will be eligible for
reimbursement and the individually reported codes will be denied.
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C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 3 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
NOTE: The Health Plan requires providers to submit a valid Clinical Laboratory
Improvement Amendment (CLIA) certificate identification number for reimbursement of
clinical laboratory services reported on a CMS-1500. If the required information is not
submitted, the Health Plan will reject or deny the claim as incomplete.
II. Modifiers
i. Technical/Professional Modifiers TC/26
• If applicable, a laboratory procedure code must be billed with the correct
modifier (TC or 26) to receive reimbursement. If a professional provider
performed both the technical and professional components of a global
procedure, then the global procedure is eligible for reimbursement only if
billed without a modifier (TC/26) and without a facility Place of Service.
• For additional details see Section II of the Related Coding section below.
ii. Laboratory Modifiers
• For conditions of reimbursement for laboratory modifiers (90, 91, and 92),
in Section II of the Related Coding section below.
III. Routine Venipuncture and the Collection of Blood Specimen
i. Routine Venipuncture/Capillary Blood Collection
• Healthcare Common Procedure Coding System (HCPCS Level II) code
S9529 and capillary blood collection CPT® code 36416, are eligible for
separate reimbursement when reported with an E&M and/or a laboratory
service. Unless an additional routine venipuncture/capillary blood collection
is clinically necessary, the frequency limit for any of these services is once
per member, per provider, per date of service. The frequency limit will also
apply to any combination of these codes reported on the same date of
service for the same member by the same provider.
• If routine venipuncture CPT® code 36415 is reported with Evaluation
and Management (E&M) office visit codes (99202-99205 and 99211-
99215) then the routine venipuncture code is included in the
reimbursement for office visit E&M services and not reimbursed
separately.
• Modifiers will not override the edit.
ii. Collection of Blood Specimen from Access Device or Catheter
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C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 4 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
• The Health Plan follows CPT® coding guidelines, which state that CPT®
codes 36591 and 36592 should not be reported in conjunction with other
services except laboratory service. Therefore, CPT® codes 36591 and
36592 are only eligible for separate reimbursement when reported with a
laboratory service.
iii. Specimen Collection, any source
• Specimen Collection for SARS-CoV-2 code C9803 reported by a
professional provider will be denied. Obtaining the sample is integral to
performing the laboratory analysis when reported by the same provider.
IV. Handling, Conveyance of Specimen, and/or Travel Allowance
The Health Plan considers the handling, conveyance, and/or travel allowance for
the pickup of a laboratory specimen to be included in a provider’s management of
a patient. Therefore, codes 99000, 99001, P9603, P9604, and H0048 are not
eligible for separate reimbursement.
Facility:
I. Handling, Conveyance of Specimen, and/or Travel Allowance
The Health Plan considers the handling, conveyance, and/or travel allowance for
the pickup of a laboratory specimen to be included in a provider’s management of
a patient. Therefore, codes 99000, 99001, P9603, P9604, and H0048 are not
eligible for separate reimbursement.
II. Routine Venipuncture and the Collection of Blood Specimen
i. Routine Venipuncture/Capillary Blood Collection.
1. Venipuncture CPT® codes 36400, 36405, 36406, 36410, 36415, and
36416 reported by an outpatient facility will be denied. These codes will
be included in the facility payment and not allowed for separate
reimbursement.
2. Modifiers will not override the edit.
ii. Collection of Blood Specimen from Access Device or Catheter
1. Collection of blood specimen CPT® codes 36591 and 36592 reported by
an outpatient facility will be denied. These codes will be included in the
facility payment and not allowed for separate reimbursement.
iii. Specimen Collection, any source
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C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 5 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
1. Specimen Collection for SARS-CoV-2 code C9803 reported by an
outpatient facility will be denied. This code will be included in the facility
payment and not allowed for separate reimbursement.
Related Coding
Description
Coding Grids
Professional Section I:
Panel Codes & Global
Codes for Complete
Blood Counts
Professional Section I: Panel Codes & Global Codes for
Complete Blood Counts
Professional Section II:
Modifiers
Professional Section II: Modifiers
Professional Section III:
Routine Venipuncture
and the Collection of
Blood Specimen
Professional Section III: Routine Venipuncture and the
Collection of Blood Specimen
Professional Section IV:
Handling, Conveyance
of Specimen, and/or
Travel Allowance
Professional Section IV: Handling, Conveyance of Specimen,
and/or Travel Allowance - Professional
Facility Section I:
Handling, Conveyance
of Specimen, and/or
Travel Allowance
Facility Section I: Handling, Conveyance of Specimen, and/or
Travel Allowance - Facility
Facility Section II:
Routine Venipuncture
and the Collection of
Blood Specimen
Facility Section II: Routine Venipuncture and the Collection of
Blood Specimen
Exemptions
Connecticut
Anthem Blue Cross and Blue Shield:
• Does not require providers to submit a valid Clinical
Laboratory Improvement Amendment (CLIA) certificate
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C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 6 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
identification number or Modifier QW for CLIA-waived
tests for reimbursement of clinical laboratory services
reported on a CMS-1500
• Allows separate reimbursement for venipuncture
(36415) when billed with E&M codes
Georgia
Anthem Blue Cross and Blue Shield allows
• separate reimbursement for venipuncture (36415) when
billed with E&M codes
• Venipuncture codes 36400, 36405, 36406, 36410,
36415, and 36416 reported by an outpatient facility
Indiana
Anthem Blue Cross and Blue Shield allows separate
reimbursement for venipuncture (36415) when billed with
E&M codes
Kentucky
Anthem Blue Cross and Blue Shield:
Facility providers are exemption from this policy.
Maine
Anthem Blue Cross and Blue Shield:
• Allows separate reimbursement for venipuncture
(36415) when billed with E&M codes
• Facility Providers are exempt from this policy.
Nevada
Anthem Blue Cross and Blue Shield allows separate
reimbursement for venipuncture (36415) when billed with
E&M codes
Wisconsin
Anthem Blue Cross and Blue Shield allows separate
reimbursement for venipuncture (36415) when billed with
E&M codes
Policy History
10/25/2023
Review approved 10/25/2023 and effective 06/01/2024:
added Facility Section II code list to not allow 36400,
36405, 36406, 36410, 36415, 36416, 36591, 36592 in an
outpatient facility; deleted modifiers from Definition section;
added back inadvertently removed language from the
Modifier 26 comment in the Section II: Modifiers code list to
not allow indicator 3 or 9 to be reimbursed in a facility
setting; updated exemption for Georgia (will allow
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C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 7 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
venipuncture codes in OP facility); added exemption for
Kentucky
06/13/2023
Review approved: no changes
12/22/2021
Revised 12/22/2021and effective 10/01/2022:
• Codes 99000 – 99001, H0048, P9603 and P9604
were removed from the Bundled Services and
Supplies Section 1 coding professional policy and
added to the Laboratory and Venipuncture Services
– Professional & Facility.
• Policy expanded to include facility: facilities will not
allow separate reimbursement for select specimen-
handling CPT/HCPCS codes 99000 – 99001,
H0048, P9603 and P9604.
• Policies added to the “Related Policies” section:
Expenses Included in Facility Services and Modifier
26 and TC: Professional and Technical Component;
removed deleted code 99201.
• Maine is exempt from the facility section of the policy.
08/07/2020
Revised: Policy language updated; modifier 90 no longer
reimbursable when reported in Place of Service 11 (Office
Visit). Implementation period extended for Virginia
(10/01/2021)
06/24/2020
Biennial Review: updated policy language and added
modifier definitions; removed definitions from the policy
body, retained edit language under laboratory Modifier 92
05/01/2020
Exemption added for Connecticut: Does not require
providers to submit a valid CLIA certificate ID number, nor
Modifier QW for CLIA-waived tests for reimbursement of
clinical lab services reported on a CMS-1500
01/17/2020
Revised: Policy language updated to require providers to
submit a CLIA certificate ID number for clinical laboratory
claims submitted on a CMS-1500 and a Modifier QW with a
CLIA certificate ID for laboratory services that require a CLIA
waiver
• Exemption added for CT
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C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 8 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
o Connecticut does not require providers to
submit a valid Clinical Laboratory Improvement
Amendment (CLIA) certificate identification
number or Modifier QW for CLIA waived tests
for reimbursement of clinical laboratory
services reported on a CMS-1500
09/01/2019
Revised: Virginia will deny venipuncture code 36415 when
billed with an E&M code
06/01/2019
Revised: Removed description section and added definition
section
08/03/2018
Revised: Modifier 92 language updated:
• “Laboratory services reported with modifier 92
(alternative laboratory platform testing) will not be
eligible for reimbursement”
o Exceptions: Procedure codes 86701-86703
and 87389 will be eligible for reimbursement
when reported with modifier 92
• Removed modifier 92 information for Cotiviti for
10/22/2017
06/01/2018
Exemption added: Connecticut will allow separate
reimbursement for venipuncture code 36415.
02/01/2018
Exemption removed: Colorado will deny venipuncture code
36415 when billed with an E&M code.
08/31/2017
Revised: (effective 01/01/2018)
Added bracketed language under section 3: “When 36415
is reported with Evaluation and Management (E&M) office
visit codes (99201-99205 and 99211-99215), it is included
in the reimbursement for office visit E&M services and is
not eligible for separate reimbursement.”
• Exemptions: Colorado, Georgia, Nevada, Indiana,
Maine, and Wisconsin will allow separate
reimbursement for venipuncture code 36415.
08/01/2017
Revised:
Added bracketed language for modifier 92 (Alternative
Laboratory Platform Testing) that only HIV testing 86701-
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C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 9 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
86703, and 87389 are allowed to be reported with modifier
92; all other lab codes will not be eligible for reimbursement
based on invalid modifier; correct coding based on CPT®
and “Coding with Modifiers”
02/07/2017
Revised: Updated information that modifier 91 will not
override the denial of component laboratory codes for the
laboratory panel bundling edit
04/05/2016
Revised: Removed reference to drug screen testing for
modifier 91 section (section II B); we do not allow modifier
override for any of the lab tests listed in frequency editing
05/05/2015
Revised:
• CPT® manual is being updated to CPT® “codebook”
to be in line with industry language
• Added 80076 – Hepatic Function Panel – to the
blood panel list
• Added language, to describe a new edit, under
section 2.A.4.:
o “when one provider reports a global
procedure and a different provider reports the
same procedure with a professional (26) or
technical (TC) component modifier, only the
first charge processed as approved by the
Health Plan will be eligible for reimbursement
and the subsequent charge processed will not
be eligible for separate reimbursement.”
• Added information under section 3.A.: HCPCS code
G0471 is eligible for separate reimbursement when
reported with a laboratory service and billed by a
professional on a CMS-1500 form.
o “the collection of venous blood by
venipuncture or urine sample by
catheterization from an individual in a skilled
nursing facility (SNF) or by a laboratory on
behalf of a home health agency (HHA)
collected by a laboratory technician that is
PDF’d 02/23/2024
C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 10 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
employed by the laboratory that is performing
the test will be eligible for separate
reimbursement when reported with a
laboratory service and billed by a professional
on a CMS-1500 Form.”
o This code is also being added to the coding
table which lists eligible services when
reported with laboratory services along with
language “according to Health Plan policy, the
following code are either eligible or not eligible
for separate reimbursement.”
02/03/2015
Annual Review with Revisions:
• Minor language updates which do not change the
policy position such as adding reference to our
Bundled Services policy
02/04/2014
Annual Review with Revisions:
• Annual review with minor
language/grammar/punctuation updates
• We are adding enhanced language on pg. 3
regarding frequency limit information to support a
future “procedure to procedure frequency shell rule”
(slated for later this year) that will allow editing
across the same/similar type of service, similar
codes; in this instance blood collection services with
any combo of 36415, 36416, and S9529—the
frequency limit is 1 per member per provider on the
same date of service same code or codes within this
grouping
o The frequency limit will also apply to any
combination of these codes reported on the
same date of service for the same member by
the same provider.
02/05/2013
Revised:
• Pg. 2, section II A.: Updated “will be denied” to “not
eligible for reimbursement”
PDF’d 02/23/2024
C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 11 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
• Pg. 3, section B: Modifier 91 language updated
o When modifier 91 (repeat clinical diagnostic
laboratory test) is appended to a reported
laboratory procedure code, our claims editing
system will override a frequency edit and allow
separate reimbursement for the repeat clinical
diagnostic laboratory test except as described
in our Frequency Editing Reimbursement
Policy related to drug screen testing
• Other minor language updates throughout the policy
01/08/2013
Revised:
• Pg. 2, policy section II, A. 2.: Removing reference to
effective date
• Pg. 3: Adding travel allowance to policy section IV
along with the codes P9603 and P9604 not
separately reimbursed
• Pg. 4: Added codes P9603 and P9604 to the coding
section as not eligible for separate reimbursement
06/05/2012
Annual review with revisions:
• Pg. 3: B. Collection of Blood Specimen
• Therefore, these codes are only eligible for separate
reimbursement when billed with a laboratory service
• Pg. 3: Under the Coding section: Codes eligible for
separate reimbursement when billed with a laboratory
service
• Added descriptions to modifiers coding section 2B
on pg. 3 and removed “Modifiers” section
• Updated the effective date, revision date, and
copyright year
06/07/2011
Revised:
PDF’d 02/23/2024
C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 12 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
• Policy language was changed “more than one will be
denied” since frequency editing never was put in
place to deny more than one.
• Policy now indicates more than one is allowed when
clinically necessary.
• Page 3 middle: Section III A. “Capillary collection”
was added to distinguish the description for 36416.
01/04/2011
Revised:
Sections III A.+B. were revised to distinguish between:
• routine venipuncture (A), which will pay with an
E&M; and
• Blood Collection 36591-36592 (B), which will not;
effective 01/01/2011, will pay with another lab
service.
The coding section was also revised to indicate 36591-
36592 is eligible for reimbursement with another lab
service.
11/02/2010
Revised:
• On page three under II. Modifiers B. The word
“Informational” in the heading was replaced with
“Laboratory.”
• Modifier 91 was removed as informational and an
explanation of the effect on claims processing was
added.
05/04/2010
Revised: Removed the word “comprehensive” from subject
02/20/2010
Initial approval and effective
References and Research Materials
This policy has been developed through consideration of the following:
• CMS
• CMS National Physician Fee Schedule Relative Value File (NPFSRVF)
• Optum EncoderPro 2023
Definitions
PDF’d 02/23/2024
C-10001 Commercial Reimbursement Policy Laboratory and Venipuncture Page 13 of 13
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield
Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc.
In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed
Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer
non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only
provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and
Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health
Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by
Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc.
trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the
Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites
or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health
Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or
administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Venipuncture
Process of withdrawing a sample of blood for the purpose of analysis
or testing.
General Reimbursement Policy Definitions
Related Policies and Materials
Bundled Services and Supplies – Professional
Frequency Editing – Professional
Modifier Rules - Professional
Expenses Included in Facility Services - Professional
Modifier 26 and TC - Professional
Use of Reimbursement Policy
This policy is subject to federal and state laws, to the extent applicable, as well as the
terms, conditions, and limitations of a member’s benefits on the date of service.
Reimbursement Policy is constantly evolving and we reserve the right to review and
update these policies periodically.
No part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechanical, photocopying, or
otherwise, without permission from Anthem Blue Cross and Blue Shield.
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