Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA00.030o


Attachment:A2

Policy #:MA00.030o

Description:HCPCS CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE

Title:Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products


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.


HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODES INCLUDED IN CAPITATION TO THE PRIMARY CARE PHYSICIAN'S (PCP'S) DESIGNATED LABORATORY SITE

NOTES:
  • The Effective Date indicates either the effective date of the code and/or the date the code became included in capitation to the outpatient laboratory.
  • The Delete Date indicates either the date the code becomes invalid and/or the date the code is no longer considered capitated to the outpatient laboratory.
HCPCS CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
HCPCS Code
Effective Date
Delete Date
G0027
10/01/2011
G0103
10/01/2011
G0123
10/01/2011
G0124
10/01/2011
G0141
10/01/2011
G0143
10/01/2011
G0144
10/01/2011
G0145
10/01/2011
G0147
10/01/2011
G0148
10/01/2011
G0306
10/01/2011
G0307
10/01/2011
G0328
10/01/2011
G0416
10/01/2011
G0417
10/01/2011
12/31/2014
G0418
10/01/2011
12/31/2014
G0419
10/01/2011
12/31/2014
G0431
10/01/2011
12/31/2015
G0432
10/01/2011
G0433
10/01/2011
G0434
10/01/2011
12/31/2015
G0435
10/01/2011
G0452
01/01/2013
G0455
01/01/2013
G0461
01/01/2014
12/31/2014
G0462
01/01/2014
12/31/2014
G0464
01/01/2015
G0475
01/01/2016
G0476
01/01/2016
G0477
01/01/2016
G0478
01/01/2016
G0479
01/01/2016
G0480
01/01/2016
G0481
01/01/2016
G0482
01/01/2016
G0483
01/01/2016
G0659










01/01/2017
G6030
01/01/2015
G6031
01/01/2015
G6032
01/01/2015
G6034
01/01/2015
G6035
01/01/2015
G6036
01/01/2015
G6037
01/01/2015
G6038
01/01/2015
G6039
01/01/2015
G6040
01/01/2015
G6041
01/01/2015
G6042
01/01/2015
G6043
01/01/2015
G6044
01/01/2015
G6045
01/01/2015
G6046
01/01/2015
G6047
01/01/2015
G6048
01/01/2015
G6049
01/01/2015
G6050
01/01/2015
G6051
01/01/2015
G6052
01/01/2015
G6053
01/01/2015
G6054
01/01/2015
G6055
01/01/2015
G6056
01/01/2015
G6057
01/01/2015
G6058
01/01/2015
G9143
10/01/2011
P2028
10/01/2011
P2029
10/01/2011
P2031
10/01/2011
P2033
10/01/2011
P2038
10/01/2011
P3000
10/01/2011
P3001
10/01/2011
P7001
10/01/2011
Q0111
10/01/2011
Q0112
10/01/2011
Q0113
10/01/2011
Q0114
10/01/2011
Q0115
10/01/2011
S3600
10/01/2011
S3620
10/01/2011
S3625
10/01/2011
S3626
10/01/2011
S3630
10/01/2011
S3645
10/01/2011
S3650
10/01/2011
S3652
10/01/2011
S3655
10/01/2011
S3708
10/01/2011
S3711
10/01/2011
03/31/2012
S3713
10/01/2011
03/31/2012
S3721
04/01/2012
12/31/2015
S3722
01/01/2012
S3800
10/01/2011
S3818
10/01/2011
03/31/2012
S3819
10/01/2011
03/31/2012
S3820
10/01/2011
03/31/2012
S3822
10/01/2011
03/31/2012
S3823
10/01/2011
03/31/2012
S3828
10/01/2011
03/31/2012
S3829
10/01/2011
03/31/2012
S3830
10/01/2011
03/31/2012
S3831
10/01/2011
03/31/2012
S3833
10/01/2011
S3834
10/01/2011
S3835
10/01/2011
03/31/2012
S3837
10/01/2011
03/31/2012
S3840
10/01/2011
S3841
10/01/2011
S3842
10/01/2011
S3843
10/01/2011
03/31/2012
S3844
10/01/2011
S3845
10/01/2011
S3846
10/01/2011
S3847
10/01/2011
03/31/2012
S3848
10/01/2011
03/31/2012
S3849
10/01/2011
S3850
10/01/2011
S3851
10/01/2011
03/31/2012
S3852
10/01/2011
S3853
10/01/2011
S3854
10/01/2011
12/31/2015
S3855
10/01/2011
12/31/2014
S3860
10/01/2011
03/31/2012
S3861
10/01/2011
S3862
10/01/2011
03/31/2012
S3865
10/01/2011
S3866
10/01/2011
S3870
10/01/2011
S3890
10/01/2011
12/31/2015


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

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