Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Policy #:MA00.030o

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) products require that the member obtain medically necessary laboratory services at the Primary Care Physician's (PCP's) designated capitated laboratory site. In most cases, laboratory services that are rendered at a non-capitated site for members enrolled in HMO or HMO-POS products are not eligible for reimbursement consideration by the Company.

The Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes listed in Attachments A1 and A2 of the policy are included in capitation as part of the Company's capitated laboratory program for members enrolled in HMO or HMO-POS products. Reimbursement for the services are provided by the Company to the designated capitated laboratory site.
  • Attachment A1: CPT Codes Included in Capitation to the PCP's Designated Laboratory Site
  • Attachment A2: HCPCS Codes Included in Capitation to the PCP's Designated Laboratory Site

In certain circumstances, medically necessary laboratory services are eligible for reimbursement by the Company to participating providers at a non-capitated site. The circumstances for which a participating provider is eligible for reimbursement at a non-capitated site are listed in Attachments B1 and B2 of the policy.
The CPT and HCPCS codes listed in Attachments B1 and B2 are eligible for reimbursement by the Company when the criteria in the policy attachment are met.
  • Attachment B1: Services Eligible for Reimbursement When Performed in the Specialist Office
    • The services described in Attachment B1 of the policy are eligible for reimbursement based on the specified provider specialty and code(s) listed.
  • Attachment B2: Services Eligible for Reimbursement When Performed in the Outpatient Hospital Laboratory
    • Services described in Attachment B2 of the policy are not eligible for reimbursement when the hospital laboratory is the member's designated capitated site.
    • Services performed in the outpatient hospital laboratory are subject to facility global payment rules. The presence of a code on Attachment B2 will not result in separate payment to the professional provider when the reimbursement to the facility includes payment for both the professional and the technical component of the service.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, laboratory services are covered under the medical benefits of the Company’s products.

BILLING GUIDELINES

A laboratory requisition form should be provided to the Primary Care Physician's (PCP's) designated capitated laboratory by the referring provider prior to services being rendered.

Description

Generally, members enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) products are required to obtain laboratory services at their primary care physician's (PCP's) designated capitated laboratory site.

There may be circumstances when it is medically necessary for laboratory services to be performed in the office of a participating professional provider or in the outpatient setting of a participating hospital that is not the member's designated capitated laboratory site.
References



Coding

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.

CPT Procedure Code Number(s)

See Attachments


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachments.


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A1: Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Description: CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE

Hide details for [<div style="position: relative; top: 0px; left: 0px;">][<span style="color:#000000; font-weight:bold" >]Attac
Attachment A2: Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Description: HCPCS CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE

[Replication or Save Conflict]
Attachment B1: Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Description: SERVICES ELIGIBLE FOR REIMBURSEMENT WHEN PERFORMED
IN THE SPECIALIST OFFICE (THIS INCLUDES THE CERTIFIED REGISTERED NURSE PRACTITIONER (CRNP) AND PHYSICIAN ASSISTANT (PA) PRACTICING WITHIN THE SCOPE OF THEIR SPECIALTY)

Attachment B2: Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Description: SERVICES ELIGIBLE FOR REIMBURSEMENT IN THE
OUTPATIENT HOSPITAL LABORATORY







Policy History

    MA00.030o:
    10/01/2019This policy has been identified for the Quarterly Code Update. This version of the policy will become effective 10/01/2019.
      • The following CPT code has been deleted from this policy: 0104U
      • The following CPT codes have been added to this policy: 0105U, 0106U, 0107U, 0108U, 0109U, 0110U, 0111U, 0112U, 0113U, 0114U, 0115U, 0116U, 0117U, 0118U, 0119U, 0120U, 0121U, 0122U, 0123U, 0124U, 0125U, 0126U, 0127U, 0128U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U


    MA00.030n
    07/01/2019This policy has been identified for the Quarterly Code Update. This version of the policy will become effective 07/01/2019.

    The following CPT codes have been added to this policy:
    0084U, 0085U, 0086U, 0087U, 0088U, 0089U, 0090U, 0091U, 0092U, 0093U, 0094U, 0095U, 0096U, 0097U, 0098U, 0099U, 0100U, 0101U, 0102U, 0103U, 0104U

    MA00.030m
    01/01/2019This version of the policy will become effective 01/01/2019.

    The following CPT codes have been deleted from this policy:
    81211, 81213, 81214

    The following CPT codes have been added to this policy:
    81163, 81164, 81165, 81166, 81167, 81171, 81172, 81173, 81174, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81204, 81233, 81234, 81236, 81237, 81239, 81271, 81274, 81284, 81285, 81286, 81289, 81305, 81306, 81312, 81320, 81329, 81333, 81336, 81337, 81343, 81344, 81345, 81443, 81518, 81596, 82642, 83722, 0080U, 0081U, 0082U, 0083U

    The following CPT code narratives have been revised in this policy:
    81162, 81212, 81215, 81216, 81217, 81244, 81287, 81327

    REVISIONS FROM MA00.030l:
    01/01/2018This policy has been identified for the CPT/HCPCS code update.

    The following LAB CPT codes have been added to Attachment A1 of this policy, effective 01/01/2018:

    0011M, 0024U, 0025U, 0026U, 0027U, 0028U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0500T, 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81175, 81176, 81230, 81231, 81232, 81238, 81247, 81248, 81249, 81258, 81259, 81269, 81283, 81328, 81334, 81335, 81346, 81361, 81362, 81363, 81364, 81448, 81520, 81521, 81541, 81551, 86794, 87634, 87662, 86008

    The following LAB CPT codes have been deleted from this policy, effective 12/31/2017:

    83499, 84061, 86185, 86243, 86378, 86729, 86822, 87277, 87470, 87477, 87515, 88154

    The following LAB code narratives have been revised in this policy, effective 01/01/2018:

    80305, 80306, 80307, 81257, 81432, 81439, 82042, 82043, 82044, 86003, 86005

    REVISIONS FROM MA00.030k:
    12/01/2017Participating Physician Assistants (PAs) practicing within the scope of their license may be eligible for reimbursement at a non-capitated site when rendered by specific specialists for services listed in Attachment B1.

    REVISIONS FROM MA00.030j:
    10/01/2017This policy has been identified for the Proprietary Laboratory Analyses (PLA) code update, effective 10/01/2017.

    The following CPT / HCPCS codes have been added to this policy: 0022U, 0023U

    REVISIONS FROM MA00.030i:
    08/21/2017 This policy has been identified for the Proprietary Laboratory Analyses (PLA) code update, effective 08/01/2017.

    The following CPT / HCPCS codes have been added to this policy:

    0012U, 0016U, 0017U

    REVISIONS FROM MA00.030h:
    08/01/2017Participating Certified Registered Nurse Practitioners (CRNPs) practicing within the scope of their license may be eligible for reimbursement at a non-capitated site when rendered by specific specialists for services listed in Attachment B1.

    REVISIONS FROM MA00.030g:
    02/01/2017This policy has been identified for the Proprietary Laboratory Analyses (PLA) code update, effective 02/01/2017.

    The following CPT / HCPCS codes have been added to this policy:
    0001U, 0002U, 0003U

    REVISIONS FROM MA00.030f:
    01/01/2017This policy has been identified for the CPT code update.

    The following CPT codes have been added to this policy, effective 01/01/2017: 80305, 80306, 80307, 81327, 81413, 81414, 81422, 81439, 81539, 84410, 87483, G0659

    The following CPT codes has been deleted from this policy, effective 12/31/2016: 80300, 80301, 80302, 80303, 80304, 81280, 81281, 81282

    The following CPT codes have narrative revisions, effective 01/01/2017: 83015, 83018, 83704, 87147, 87197, 87253

    REVISIONS FROM MA00.030e:
    01/01/2016This policy has been identified for the CPT code update effective 01/01/2016.

    The following codes have been added: 80081, 81490, 81493, 81525, 81528, 81535, 81536, 81538, 81540, 81545, 81595, 88350, 0423T, G0475, G0476, G0477, G0478, G0479, G0480, G0481, G0482, G0483, 81162, 81170, 81218, 81219, 81272, 81273, 81276, 81311, 81314, 81412, 81432, 81433, 81434, 81437, 81438, 81442

    The following codes have been termed: 82486, 82487, 82488, 82489, 82491, 82541, 82543, 82544, 83788, 88347, 0103T, S3721, S3854, S3890, G0431, G0434

    REVISIONS FROM MA00.030d:
    12/01/2015The following CPT code has been termed from this policy, effective 11/30/2015:

    86580

    Per Steering committee, decision was made to term from MA00.030d and add to MA00.033b: Services Paid Above Capitation for Health Maintenance Organization (HMO) Primary Care Physicians.

    86580 is NOT a lab – it is a diagnostic test – even though it has a 8000 series code.

    REVISIONS FROM MA00.030c:
    07/01/2015This policy has been identified for CPT code update, effective 07/01/2015.

    The following CPT codes been added to this policy: 0009M, 0010M

    REVISIONS FROM MA00.030b:
    03/01/2015Policy MA00.030a has been revised. The policy will be reissued as MA00.030b effective 04/08/2015.
    • The specialty, Interventional Cardiology, is a new specialty effective 01/01/2015. The specialty was added to this policy to correspond with Cardiology
    • Added service code 83880 effective 12/10/2014.

    REVISIONS FROM MA00.030a:
    01/02/2015Policy # MA00.030 has been identified for the 2015 annual CPT code update. The policy will be reissued as MA00.030a.

    The following codes have been deleted from Attachments A1/A2:
    80100, 80101, 80102, 80103, 80104, 80152, 80154, 80160, 80166, 80172, 80174, 80182, 80196, 80440, 82000, 82003, 82055, 82101, 82145, 82205, 82520, 82646, 82649, 82651, 82654, 82666, 82690, 82742, 82953, 82975, 82980, 83008, 83055, 83071, 83634, 83805, 83840, 83858, 83866, 83887, 83925, 84022, 84127, 87001, 87620, 87621, 87622, 88343, 88349, G0417, G0418, G0419, G0461,G0462

    The following codes have been revised from Attachments A1/A2:
    80162, 80164, 80171, 80299, 81245, 82541, 82542, 82543, 82544, 84600, 86900, 86901, 86902, 86904, 86905, 86906, 87501, 87502, 87503, 87631, 87632, 87633, 88342, 88360, 88361, 88365, 88367, 88368, G0416

    The following codes have been added from Attachments A1/A2:
    80163, 80165, 80300, 80301, 80302, 80303, 80304, 80320, 80321, 80322, 80323, 80324, 80325, 80326, 80327, 80328, 80329, 80330, 80331, 80332, 80333, 80334, 80335, 80336, 80337, 80338, 80339, 80340, 80341, 80342, 80343, 80344, 80345, 80346, 80347, 80348, 80349, 80350, 80351, 80352, 80353, 80354, 80355, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80363, 80364, 80365, 80366, 80367, 80368, 80369, 80370, 80371, 80372, 80373, 80374, 80375, 80376, 80377, 81246, 81288, 81313, 81410, 81411, 81415, 81416, 81417, 81420, 81425, 81426, 81427, 81430, 81431, 81435, 81436, 81440, 81445, 81450, 81455, 81460, 81465, 81470, 81471, 81519, 83006, 87505, 87506, 87507, 87623, 87624, 87625, 87806, 88341, 88344, 88364, 88366, 88369, 88373, 88374, 88377, G0464, G6030, G6031, G6032, G6034, G6035, G6036, G6037, G6038, G6039, G6040, G6041, G6042, G6043, G6044, G6045, G6046, G6047, G6048, G6049, G6050, G6051, G6052, G6053, G6054, G6055, G6056, G6057, G6058

    MA00.030:
    01/01/2015This is a new policy.




    Version Effective Date: 10/01/2019
    Version Issued Date: 10/24/2019
    Version Reissued Date: N/A