Effective Date: October 1, 2021

Purpose:
This reimbursement policy provides guidelines on how to bill for travel allowance for specimen collection from homebound or nursing homebound patient for codes P9603 or P9604 when billed without a specimen collection code. 

Scope:
Products included:

• NJ FamilyCare/Medicaid

Definitions:

• P9603: Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated miles actually travelled or just “One-way allow prorated miles” for short, used in Diagnostic laboratory.
• P9604: Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge.

Policy:
In accordance with CMS Guidelines, Horizon NJ Health will consider for reimbursement procedures P9603 and P9604 when billed with a specimen collection code.

Procedure:
Horizon NJ Health will not consider for reimbursement P9603 or P9604 (Travel allowance one way in connection with medically necessary laboratory specimen) when billed without a specimen collection code.

Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

References:
CMS Manual System, Medicare Claims Processing, Transmittal 4495, January 17, 2020 “Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens” https://www.cms.gov/files/document/r4495cp.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services