Mobile phlebotomy involves a trained technician traveling to a patient’s residence to collect a blood specimen, offering convenience for individuals with mobility challenges. Medicare coverage and payment for this mobile service are highly regulated and depend on meeting specific criteria, primarily medical necessity. Medicare payment is not a simple flat fee but a structured calculation. This system ensures payment is made only when the service is a required part of a beneficiary’s treatment plan and cannot be reasonably obtained elsewhere.
Defining Mobile Phlebotomy Coverage Under Medicare
Medicare coverage for mobile phlebotomy requires medical necessity, specifically that the patient must be considered homebound. A patient is defined as homebound if leaving their residence without significant difficulty or a taxing effort is medically contraindicated. The patient’s physician must certify this homebound status, which is the foundational requirement for any payment related to a home draw.
Leaving the home must require the aid of supportive devices, special transportation, or the assistance of another person due to illness or injury. A patient does not need to be bedridden to be classified as homebound. Absences from the home are permitted only if they are infrequent, of short duration, or directly related to receiving necessary medical treatment. Medicare covers the specimen collection when this medical necessity is established.
The rules for reimbursing travel fees are separate from the payment for the actual specimen collection. While Medicare covers the collection fee for a homebound patient, the rules for allowing a travel allowance are more restrictive. The phlebotomy service must be ordered by a physician as part of a plan of care. Without documented medical necessity preventing the patient from traveling to a lab, the mobile service is generally not covered.
Determining Reimbursement Rates
Medicare’s payment for mobile phlebotomy is determined by the Clinical Laboratory Fee Schedule (CLFS). Payment for the blood draw is usually bundled into the payment for the laboratory test performed on the specimen. Medicare allows a separate specimen collection fee when a technician must draw a specimen from a homebound or institutionalized patient.
For 2024, the general specimen collection fee is $8.83. This increases to $10.83 when the specimen is collected from a Medicare patient in a skilled nursing facility or on behalf of a home health agency. This fee is allowed only once per patient encounter, regardless of the number of tubes or types of specimens collected during that single visit. The payment for the laboratory test itself is subject to the National Limitation Amount (NLA), which ensures Medicare does not pay more than the lowest of the billed charge, a local fee schedule, or the NLA.
Medicare may also pay a travel allowance to cover the technician’s travel costs. This allowance covers estimated travel expenses, including the technician’s salary and travel for the trip. The travel allowance is paid only if a specimen collection fee is also payable, linking reimbursement directly to the medical necessity of the home draw. The travel reimbursement is calculated either on a flat-rate or per-mile basis, depending on the distance traveled and the local Medicare Administrative Contractor’s (MAC) policy.
Billing Codes and Documentation Requirements
Providers must use specific billing codes and maintain documentation to receive reimbursement for mobile phlebotomy services. The actual venipuncture procedure is typically billed using standard Current Procedural Terminology (CPT) code 36415 for routine venous blood collection. This code alone does not account for the mobile aspect of the service.
The travel component is billed using specific Healthcare Common Procedure Coding System (HCPCS) codes P9603 or P9604. P9604 is used for a flat-rate travel allowance when the round trip is 20 eligible miles or less. P9603 is used for the per-mile travel allowance when the average trip is longer than 20 miles round trip.
The per-mile rate for P9603 was $1.13 for 2024. The flat-rate trip allowance (P9604) for 2024 was $11.30, and this rate is prorated by the number of patients seen on that single trip. The laboratory must divide the travel cost among all patients from whom a specimen collection fee is paid during that trip, regardless of whether they are Medicare beneficiaries.
Without correct documentation, especially the physician’s certification of the patient’s homebound status, the travel portion of the bill will not be reimbursed. The laboratory must correctly use these specific HCPCS codes and accurately prorate the travel allowance. The correct place of service code, such as “12” for a patient’s home, must also be included on the claim to indicate the non-facility setting.
Patient Financial Responsibility
Mobile phlebotomy services, when covered, fall under Medicare Part B, which covers outpatient services and diagnostic tests. The patient is responsible for standard out-of-pocket costs associated with Part B after the services are deemed medically necessary. The beneficiary must first meet the annual Part B deductible before Medicare begins payment.
After the deductible is met, Medicare generally pays 80% of the approved amount for the service. The patient is responsible for the remaining 20% as a coinsurance. This coinsurance applies to the specimen collection fee, the travel allowance, and the cost of the underlying laboratory test.
Patients with secondary insurance, such as a Medigap policy or Medicaid, may have their deductible and 20% coinsurance covered. If the service is determined not to be medically necessary, the provider should issue an Advanced Beneficiary Notice (ABN) to the patient. An ABN informs the patient that Medicare may not cover the service, making the patient potentially responsible for the full cost.