Claims & Payment Policy CP-158: Dipstick, Venipuncture, & Catheter Edits CORRECTION

June 8, 2021

Claims & Payment Policy Dipstick, Venipuncture, & Catheter Edits (Kentucky Medicaid Only)

Correction: In our prior notice, we erroneously included CPT code 80305 among the codes listed below that are affected by the edits. We would like to clarify that the actual policy does NOT include CPT code 80305 and CPT code 80305 was NOT included in the edits that were implemented. We apologize for the error and are issuing this corrected notice for clarity.

WellCare is implementing a policy for Dipstick, Venipuncture, & Catheter Edits (Kentucky Medicaid Only) with an effective date of March 18, 2021.

Summary of Policy:

This policy addresses the Department for Medicaid Services (DMS) reimbursement policies pertaining to dipstick, venipuncture, and catheter laboratory services for professional provider claims submitted on a Form CMS-1500, whether performed in a provider’s office, a hospital laboratory, or an independent laboratory.

Kentucky Legislative Research Commission, Section 6. Laboratory, Venipuncture, and Catheter policy: 907 KAR 3:010 states the following:

Section 6. Laboratory, Venipuncture, and Catheter

(1) Except for a service specified in paragraph (a) or (b) of this subsection, a physician laboratory service shall be reimbursed in accordance with 907 KAR 1:028.

(a) Charges for a laboratory test performed by dipstick or reagent strip or tablet in a physician's office shall be included in the office visit charge.

(b) A routine venipuncture procedure shall not be separately reimbursed if submitted with a charge for an office, hospital, or emergency room visit or in addition to a laboratory test.

(2) Reimbursement for placement of a central venous, arterial, or subclavian catheter shall be:

(a) Included in the fee for the anesthesia if performed by the anesthesiologist;

(b) Included in the fee for the surgery if performed by the surgeon; or

(c) Included in the fee for an office, hospital, or emergency room visit if performed by the same provide

What does this mean for providers?

In accordance with Kentucky state regulations, routine venipuncture (CPT code 36415 and HCPCS code S9529), dipstick (CPT codes 81002 and 81003), and catheter (CPT codes 36620, 36625, 36640, 36555-36558, 36568, 36569, 36572, 36573, 36578, 36580, 36581, and 36584) services are included in the reimbursement for office, hospital, ER, critical care, anesthesia, surgery, or lab E&M services and are not reimbursed separately. Claims may be denied if they are not submitted with the correct coding.

Note: Modifier 25 is exempt for use in accordance with Kentucky Legislative Research Commission, Section 6. Laboratory, Venipuncture, and Catheter policy: 907 KAR 3:010.

Appeals Process

If denied, beneficiaries and/or providers may appeal to WellCare per federal and state appeal statutes and regulations.

Providers can review the complete policy at www.wellcare.com/providers, select Kentucky, select Claims, and then select Payment Policy.

We are here to help. Please contact your Provider Relations Representative for general inquiries regarding this program.

Sincerely,

WellCare Health Plans