HCPCS Code P9604 – Description & Clinical Examples

This article will define HCPCS Code P9604, explain the medical necessity to report HCPCS P9604, the guidelines and clinical examples of HCPCS P9604.

HCPCS Code P9604 Description

HCPCS Code P9604 is defined by the HCPCS manual as follows (the text in Italic is the official definition of HCPCS P9604):

One-way travel allowance in connection with the collection of medically necessary laboratory samples taken from a home-bound or nursing home patient; proportional travel expenses.

CMS will pay a minimum of $10.30 (CY 2020) a one-way flat rate. The flat-rate travel allowance will be used in areas where average journeys are less than 20 miles round trip. The flat-rate travel rate will be prorated for more than one blood draw at the same address and for stops at Medicare and non-Medicare patients’ homes. The laboratory makes the breakdown when the request is submitted based on the quantity of patients visited on that journey. The sample collection fee will be paid for each meeting with the patient.

This fare is based on the assumption that a journey is an average of 15 minutes and up to 10 miles one way. It uses the federal mileage rate and lab technician time of $17.66 per hour, including overheads. Contractors have the option of setting a flat rate above the $10.00 minimum, if local conditions allow for it. The national minimum flat rate will be revised and updated to coincide with the medical laboratory rate if necessary for federal travel allowance and salary adjustments.

HCPCS Code P9604 Examples

Example 1

A laboratory technician travels from the laboratory to a single Medicare patient’s home and returns to the laboratory without making any other stops. The flat rate would be calculated as follows: 2 x $10.00 for a total trip reimbursement of $20.00, plus the specimen collection fee.

Example 2

A laboratory technician travels from the laboratory to the homes of five patients to draw blood, four of the patients are Medicare patients and one is not. An additional flat rate would be charged to cover the 5 stops and the return trip to the lab (6 x $10.00 = $60.00). Each of the claims submitted would be for $12.00 ($60.00/5 = $12.00). Since one of the patients is non-Medicare, four claims would be submitted for $12.00 each, plus the specimen collection fee for each.

Example 3

A laboratory technician travels from a laboratory to a nursing home and draws blood from 5 patients and returns to the laboratory. Four of the patients are on Medicare and one is not. The $10.00 flat rate is multiplied by two to cover the return trip to the laboratory (2 x $10.00 = $20.00) and then divided by five (1/5 of $20.00 = $4.00). Since one of the patients is non-Medicare, four claims would be submitted for $4.00 each, plus the specimen collection fee.