Notification

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


Notification Issue Date: 02/14/2020



Policy Attachment

Attachment to Policy # MA00.010z


Attachment:B3

Policy #:MA00.010z

Description:Laboratory Network Rules and Limited Circumstances cont'd.

Title:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.



LABORATORY NETWORK RULES AND LIMITED CIRCUMSTANCES

LIMITED CIRCUMSTANCES PROCEDURE CODE LIST

The limited circumstances of laboratory services that a participating specialist, other than an independent or a physiological laboratory, may provide, and for which the provider may be eligible for reimbursement, are listed below:

All Professional Specialties
(In All Places of Service)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
86328
04/10/2020
86769
04/10/2020
87635
03/13/2020
G2023
03/01/2020
G2024
03/01/2020
U0001
02/04/2020
U0002
02/04/2020
U0003
04/14/2020
U0004
04/14/2020
ALL Professional Specialties
(Office and Outpatient Place of Service)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
86580
01-01-1982
87899
01-01-1998

Cardiology and Interventional Cardiology
(Office Place of Service Only)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
83880
12-10-2014

Dermatology
(Office Place of Service Only)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
87220
01-01-2017
88302
01-01-1982
05-18-2020
88304
01-01-1985
05-18-2020
88305
01-01-1982
05-18-2020
88312
01-01-1982
05-18-2020
88313
01-01-1982
05-18-2020
88321
01-01-1982
05-18-2020
88331
59
07-31-2013
88341
01-01-2015
05-18-2020
88342
01-01-1985
05-18-2020

Hematology/Oncology, Medical Oncology, Pediatric Hematology and Oncology
(Office and Outpatient Place of Service)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
G0306
01-01-2004
G0307
01-01-2004
85004
01-01-2003
85008
01-01-2017
85014
01-01-1984
85025
01-01-1987
85027
01-01-1985
85032
01-01-2003
85044
01-01-2017
85048
01-01-1984
85049
01-01-2003

Hematology/Oncology
(Office and Outpatient Place of Service)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
88738
01-01-2010

Nephrology
(Office and Outpatient Place of Service)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
81007
01-01-2017

Ophthalmology/Optometry
(Office and Outpatient Place of Service)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
83861
01-01-2014

Oral and Maxillofacial Pathology
(Office Place of Service Only)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
88313
01-01-1982
03-31-2018
88313
26
01-01-1982
03-31-2018
88341
01-01-2015
03-31-2018
88341
26
01-01-2015
03-31-2018
88342
01-01-1985
03-31-2018
88342
26
01-01-1985
03-31-2018
88304
26
01-01-1985
03-31-2018
88305
26
01-01-1985
03-31-2018
88312
26
01-01-1982
03-31-2018

Oral and Maxillofacial Pathology
(Outpatient Place of Service only )
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
88304
26
01-01-1985
88305
26
01-01-1985
88307
26
01-01-1982
88311
26
01-01-1982
88312
26
01-01-1982
88313
26
01-01-1982
88313
01-01-1982
88341
01-01-2015
88341
26
01-01-2015
88342
01-01-1985
88342
26
01-01-1985
88346
26
01-01-1985
88365
26
01-01-1989

Orthopedic Surgeon
(Outpatient Place of Service Only)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
83872
01-01-2017
89050
01-01-2017
89051
01-01-2017
89060
01-01-2017

Pathology, Anatomic Pathology and Anatomic and Clinical Pathology
(Office Place of Service Only)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
88305
01-01-1982
03-31-2018

Pathology, Anatomic Pathology and Anatomic and Clinical Pathology
(Office Place of Service Only)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
88187
07-01-2009
03-31-2018
88188
07-01-2009
03-31-2018
88189
07-01-2009
03-31-2018
88291
07-01-2009
03-31-2018
88302
26
01-01-1982
03-31-2018
88304
26
01-01-1985
03-31-2018
88305
26
01-01-1982
03-31-2018
88312
26
01-01-1982
03-31-2018
88313
26
01-01-1982
03-31-2018
88321
26
01-01-1982
03-31-2009
88341
26
01-01-2015
03-31-2018
88342
26
01-01-1985
03-31-2018

Pathology, Anatomic Pathology and Anatomic and Clinical Pathology
(Outpatient Place of Service Only)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
88104
26
11-01-2009
88106
26
11-01-2009
88107
26
11-01-2009
12-31-2011
88108
26
11-01-2009
88112
26
11-01-2009
88125
26
11-01-2009
88130
11-01-2009
88140
11-01-2009
88155
11-01-2009
88160
26
11-01-2009
88161
26
11-01-2009
88162
26
11-01-2009
88172
26
11-01-2009
88173
26
11-01-2009
88182
26
11-01-2009
88187
07-01-2009
88188
07-01-2009
88189
07-01-2009
88230
11-01-2009
88233
11-01-2009
88235
11-01-2009
88237
11-01-2009
88239
11-01-2009
88240
11-01-2009
88241
11-01-2009
88245
11-01-2009
88248
11-01-2009
88249
11-01-2009
88261
11-01-2009
88262
11-01-2009
88263
11-01-2009
88264
11-01-2009
88267
11-01-2009
88269
11-01-2009
88271
11-01-2009
88272
11-01-2009
88273
11-01-2009
88274
11-01-2009
88275
11-01-2009
88280
11-01-2009
88283
11-01-2009
88285
11-01-2009
88289
11-01-2009
88291
07-01-2009
88300
26
11-01-2009
88302
26
01-01-1982
88304
26
01-01-1985
88305
26
01-01-1982
88307
26
11-01-2009
88309
26
11-01-2009
88311
26
11-01-2009
88312
26
01-01-1982
88313
26
01-01-1982
88314
26
11-01-2009
88318
26
11-01-2009
12-31-2011
88319
26
11-01-2009
88321
26
01-01-1982
03-31-2009
88323
26
11-01-2009
88331
26
11-01-2009
88332
26
11-01-2009
88333
26
11-01-2009
88334
26
11-01-2009
88341
26
01-01-2015
88342
26
01-01-1985
88346
26
11-01-2009
88347
26
11-01-2009
12-31-2015
88348
26
11-01-2009
88349
26
11-01-2009
12-31-2014
88356
26
11-01-2009
88358
26
11-01-2009
88360
26
11-01-2009
88361
26
11-01-2009
88362
26
11-01-2009
88365
26
11-01-2009
88367
26
11-01-2009
88368
26
11-01-2009

Rheumatology and Pediatric Rheumatology
(Office and Outpatient Place of Service)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
G0306
01-01-2004
G0307
01-01-2004
Q0114
01-01-1994
83872
01-01-1984
85004
01-01-2003
85014
01-01-1984
85025
01-01-1987
85027
01-01-1985
85032
01-01-2003
85044
01-01-2017
85048
01-01-1984
85049
01-01-2003
85055
01-01-2004
85810
07-01-2009
88738
01-01-2010
89050
01-01-1984
89051
01-01-1984
89055
01-01-2017
89060
01-01-1986

Reproductive Endocrinology
(Office Place of Service)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
89250
07-01-2011
89251
01-01-2016
89253
07-01-2011
89254
01-01-2016
89255
07-01-2011
89257
07-01-2011
89258
01-01-2016
89259
01-01-2016
89260
07-01-2011
89261
01-01-2016
89264
01-01-2016
89268
01-01-2016
89272
01-01-2016
89280
07-01-2011
89281
01-01-2016
89290
01-01-2016
89291
01-01-2016

Reproductive Endocrinology
(Office and Outpatient Place of Service)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
82670
01-01-1984
82671
01-01-2017
82672
01-01-2017
83001
01-01-1984
83002
01-01-1984
84144
01-01-1984
84702
01-01-1987
84703
01-01-1987
84704
01-01-2017
84830
01-01-2017
89300
01-01-1984
89310
01-01-1984
89320
01-01-1984
89321
01-01-2016
89322
01-01-2016
89325
01-01-2016
89329
01-01-2016
89330
01-01-2016
89331
01-01-2016
89335
01-01-2017
89337
01-01-2017
89352
01-01-2017
89353
01-01-2017
89354
01-01-2017
89356
01-01-2017
89398
01-01-2016

Urology
(Office and Outpatient Place of Service)
Procedure Code
Modifier
Date Code Added to the Policy
Date Code Removed from the Policy
81007
01-01-2017
81020
01-01-2017
89300
01-01-2017
89310
01-01-1984
89320
01-01-1984
89321
01-01-2016
89322
01-01-2016



Version Effective Date: 05/18/2020
Version Issued Date: 05/18/2020
Version Reissued Date: N/A

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