Why don't we always receive payment on lab-only claims?

Q: I have a follow-up question to last week’s answer about lab payments. We should receive payment for a lab-only claim because of the new Q4 status indicator. However, we noticed that sometimes we do and sometimes we don’t. The difference seems to be when we report a venipuncture and when we report the blood being drawn from a ventricular assist device (VAD). When the venipuncture is reported, we get paid for all line items. When the blood draw is from a VAD, we don’t get paid for the lab work. Is this correct?

A: Actually, this is correct. When you look at the OPPS payment status for Q4, it is paid separately only when it is the only status indicator on the claim. When a lab service (status indicator Q4) is reported in combination with status indicators J1, J2, S, T, V, Q1, Q2, or Q3, then it becomes a packaged service. That is how it gets the definition of “conditionally packaged.” The condition depends on the other services on the claim.

When we look at Addendum B of the 2016 OPPS final rule, the CPT® code for venipuncture (36415) has a status indicator of Q4, so all the lab services and the venipuncture will be reimbursed. When we look at the CPT codes for blood drawn from a VAD (36591 and 36592), they are both assigned to status indicator Q1. Based on the claims processing rules, the I/OCE packages the Q4 item into the Q1 item and provides payment for the Q1 service. So in these cases, you will receive payment on the line items with CPT codes 36591 and 36592 (blood drawn from VAD) rather than individual line item payment for all services on the claim.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.