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HCPCS P9604 · Level II · P code

P9604: One-way allow prorated trip, HCPCS Level II P code

Compiled from CMS files by the QuickIntell RCM Editorial Team · Data effective · Method: reference methodology · Report a data correction

Data currency: HCPCS Level II file: October 2026 (effective October 1, 2026); PFS relative value file: RVU26D, released August 26, 2026 (effective October 1, 2026); NCCI MUE tables: 2026 Q4 (effective October 1, 2026); NCCI PTP edits: v323r0 (2026 Q4) (effective October 1, 2026); OPPS Addendum B: October 2026 (effective October 1, 2026). Next CMS release: January 1, 2027 (quarterly update) for the HCPCS Level II file and NCCI MUE tables and NCCI PTP edits and OPPS Addendum B; RVU27A with the CY2027 PFS final rule, effective January 1, 2027 for the PFS relative value file.

Key facts for P9604

Medicare payment
no PFS amount
PFS status X; OPPS SI A: paid under another fee schedule or system
Coverage code
D
special coverage instructions apply
Practitioner MUE
2
MAI 3
OPPS status
SI A
Services not paid under OPPS; paid under fee schedule or other payment system
NCCI PTP pairs
1
1 hospital outpatient
LCDs and articles
0 / 0

TL;DR

P9604 is a Level II code from the P section (pathology and laboratory services), in use since 1987: "Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge". The physician fee schedule lists P9604 with status X (statutory exclusion: not a physician service under the fee schedule), so the PFS carries no national amount for it. Its OPPS status indicator is A, which the I/OCE table defines as "Services not paid under OPPS; paid under fee schedule or other payment system": Medicare pays P9604 under a fee schedule or payment system other than OPPS. CMS caps P9604 at practitioner 2 (MAI 3, Clinical: Data); hospital outpatient 2 (MAI 3, Clinical: Data) units per day in the 2026 Q4 MUE tables. In the NCCI PTP files v323r0 P9604 appears in 1 practitioner pairs as column 2 and 0 as column 1 (most often with P9603), and in 1 hospital outpatient pairs as column 2 and 0 as column 1. P9604 appears in no active LCD or billing and coding article, so coverage follows HCPCS coverage code D (special coverage instructions apply) and any NCD. HCPCS record: BETOS Y2 (other - non-Medicare fee schedule); pricing indicator 22; type of service 5 (diagnostic laboratory). 1 other active code opens with "Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient"; related codes: P9603, P9612, P9073, P9060.

P9604 descriptor and code status

The October 2026 HCPCS Level II file describes P9604 as “Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge”. It sits in the P section (pathology and laboratory services), listed with the other P codes. Although searches often call it the "P9604 CPT code", P9604 is a HCPCS Level II code maintained by CMS, not an AMA CPT code; both go in the same procedure-code field on the claim.

HCPCS file attributes of P9604
FieldValue
Short descriptorOne-way allow prorated trip
Added to HCPCS1987-01-01
Last actionN (no maintenance), effective 1992-01-01
Coverage codeD: special coverage instructions apply
Pricing indicator22: clinical lab fee schedule, priced by the contractor
BETOS categoryY2: other - non-Medicare fee schedule
Type of service5: diagnostic laboratory

Medicare payment for P9604

The physician fee schedule lists P9604 with status X (statutory exclusion: not a physician service under the fee schedule), so the PFS carries no national amount for it. Its OPPS status indicator is A, which the I/OCE table defines as "Services not paid under OPPS; paid under fee schedule or other payment system": Medicare pays P9604 under a fee schedule or payment system other than OPPS. The amounts below are national figures from the October 2026 CMS files; the contractor applies the locality, rural or state adjustment and the beneficiary's cost sharing.

Physician fee schedule (RVU26D)

Status X: statutory exclusion: not a physician service under the fee schedule. Global period XXX (global surgery concept does not apply); PC/TC indicator 9 (professional/technical concept does not apply).

Hospital outpatient (OPPS Addendum B)

Status indicator A (Services not paid under OPPS; paid under fee schedule or other payment system), with no separate OPPS payment rate.

Medically Unlikely Edits for P9604

CMS caps P9604 at practitioner 2 (MAI 3, Clinical: Data); hospital outpatient 2 (MAI 3, Clinical: Data) units per day in the 2026 Q4 MUE tables. The practitioner MUE is a date-of-service clinical edit: units above the limit deny but can be paid on appeal with documentation.

MUE values for P9604 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services23 Date of Service Edit: ClinicalClinical: Data
Facility outpatient hospital23 Date of Service Edit: ClinicalClinical: Data

The MUE lookup for P9604 shows every setting next to any other code on the same claim.

NCCI edits and add-on rules

In the practitioner PTP file v323r0, P9604 is the column-2 (bundled) code in 1 active pair, 100% of which allow a modifier and the column-1 code in 0; 0 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: Mutually exclusive procedures.

Column-1 codes most often paired with P9604 (practitioner)
Column-1 codePairs
P9603 One-way allow prorated miles1

In the hospital outpatient PTP file v323r0, P9604 is the column-2 (bundled) code in 1 active pair, 100% of which allow a modifier and the column-1 code in 0; 0 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: Mutually exclusive procedures.

Column-1 codes most often paired with P9604 (hospital outpatient)
Column-1 codePairs
P9603 One-way allow prorated miles1

P9604 is neither an add-on code nor a designated primary code in the 2026 Q4 NCCI add-on edit file.

Pair counts show exposure, not the answer for one claim. Check P9604 against a second code to see whether the pair bundles and whether a modifier can separate the services.

Medicare coverage policies for P9604

No current LCD or billing and coding article lists P9604. The HCPCS coverage code D means special coverage instructions apply, and any National Coverage Determination for the service still applies.

Denials to expect on P9604

CARC 50 · N115

the service is not reasonable and necessary for the diagnosis on the claim

CARC 151 · N362

units of P9604 exceed the practitioner MUE of 2 per date of service

CARC 4

the modifier reported is inconsistent with the code

CARC 16

the claim lacks information needed to adjudicate the line, such as an order, NPI or required modifier

Where QuickIntell fits for P9604 claims

QuickCode supports qualified coder review of units, modifiers and NCCI pairs for P9604 before the claim leaves, and QuickRCM carries claim readiness and the denial follow-up when an edit or coverage policy is missed.

See QuickCode for coder reviewSee QuickRCM for denial follow-upBook a meeting

Frequently asked questions: HCPCS P9604

What does HCPCS code P9604 describe?

"Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge" (short descriptor "One-way allow prorated trip"), in the P section (pathology and laboratory services). Added 1987-01-01; last action N (no maintenance) effective 1992-01-01.

Is P9604 a CPT code?

It is not. P9604 belongs to the P section (pathology and laboratory services) of HCPCS Level II, the CMS code set, not to AMA CPT. "P9604 CPT code" searches refer to it.

What does Medicare pay for P9604?

The physician fee schedule lists P9604 with status X (statutory exclusion: not a physician service under the fee schedule), so the PFS carries no national amount for it. Its OPPS status indicator is A, which the I/OCE table defines as "Services not paid under OPPS; paid under fee schedule or other payment system": Medicare pays P9604 under a fee schedule or payment system other than OPPS.

How many units of P9604 can be billed per day?

CMS caps P9604 at practitioner 2 (MAI 3, Clinical: Data); hospital outpatient 2 (MAI 3, Clinical: Data) units per day in the 2026 Q4 MUE tables. For the practitioner MUE (MAI 3), units above 2 deny for the day but can be paid on appeal with documentation; denials arrive as CARC 151.

Does Medicare cover P9604?

P9604 appears in no active LCD or billing and coding article, so coverage follows HCPCS coverage code D (special coverage instructions apply) and any NCD.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.

Disclaimer

This page is an operational reference compiled from CMS publications: the HCPCS Level II file, the physician, DMEPOS and clinical laboratory fee schedules, OPPS and ASC addenda, NCCI MUE, PTP and add-on edit tables and the Medicare Coverage Database. Amounts are Medicare national figures before locality and state adjustment; Medicaid and commercial payers set their own. CPT codes are shown as numbers only; CPT descriptors are copyright AMA. Nothing here is legal, clinical or billing advice.

Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.