Notification

eviCore Lab Management Program (Independence)


Notification Issue Date: 12/02/2019



Policy Attachment


Attachment to Policy # 06.02.52o


Attachment:A

Policy #:06.02.52o

Description:Procedure Codes Requiring Pre-service and Prepayment Reviews

Title:eviCore Lab Management Program (Independence)


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 FOLLOWING PROCEDURE CODES REPRESENTING GENETIC/GENOMIC TESTS REQUIRE PRE-SERVICE REVIEWS AND WILL UNDERGO PREPAYMENT REVIEWS BY CARECORE NATIONAL, LLC d/b/a EVICORE HEALTHCARE:


Molecular Pathology (Genetic/Genomic Testing)
Code
0001U
0005U
0012U
0013U
0014U
0016U
0017U
0018U
0019U
0022U
0026U
0029U
0030U
0031U
0032U
0033U
0034U
0036U
0040U
0045U
0047U
0048U
0050U
0053U
0055U
0056U
0060U
0067U
0069U
0070U
0071U
0072U
0073U
0074U
0075U
0076U
0078U
0079U
0084U
0087U
0088U
0089U
0090U
0094U
0101U
0102U
0103U
0111U
0113U
0114U
0118U
0120U
0129U
0130U
0131U
0132U
0133U
0134U
0135U
0136U
0137U
0138U
0153U
0156U
0157U
0158U
0159U
0160U
0161U
0162U
81162
81163
81164
81165
81166
81167
81173
81174
81185
81186
81189
81190
81201
81202
81203
81212
81215
81216
81217
81221
81222
81223
81225
81226
81227
81228
81229
81230
81231
81232
81238
81248
81249
81252
81253
81257
81258
81259
81269
81277
81283
81286
81289
81291
81292
81293
81294
81295
81296
81297
81298
81299
81300
81302
81303
81304
81306
81307
81308
81313
81317
81318
81319
81321
81322
81323
81325
81326
81327
81328
81335
81336
81337
81343
81346
81350
81355
81361
81362
81363
81364
81400
81401
81402
81403
81404
81405
81406
81407
81408
81410
81411
81412
81413
81414
81415
81416
81417
81425
81426
81427
81430
81431
81432
81433
81434
81435
81436
81437
81438
81439
81440
81442
81443
81445
81448
81450
81455
81460
81465
81470
81471
81493
81518
81522
81542
81552

Multianalyte Assays with Algorithmic Analyses (MAAA) (Genetic/Genomic Testing)
Code
0004M
0006M
0007M
0008M
0011M
0012M
81504
81519
81520
81521
81525
81540
81541
81545
81551
81595

Unlisted Molecular Codes (When Reported for Genetic/Genomic Testing)
Code
81479
81599
84999

Molecular HCPCS Codes (Genetic/Genomic Testing)
Code
Narrative
G9143
Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s)
S3800
Genetic testing for amyotrophic lateral sclerosis (als)
S3840
Dna analysis for germline mutations of the ret proto-oncogene for susceptibility to multiple endocrine neoplasia type 2
S3841
Genetic testing for retinoblastoma
S3842
Genetic testing for von hippel-lindau disease
S3844
Dna analysis of the connexin 26 gene (gjb2) for susceptibility to congenital, profound deafness
S3845
Genetic testing for alpha-thalassemia
S3846
Genetic testing for hemoglobin e beta-thalassemia
S3850
Genetic testing for sickle cell anemia
S3852
Dna analysis for apoe epsilon 4 allele for susceptibility to alzheimer's disease
S3854
Gene expression profiling panel for use in the management of breast cancer treatment
S3861
Genetic testing, sodium channel, voltage-gated, type v, alpha subunit (scn5a) and variants for suspected brugada syndrome
S3865
Comprehensive gene sequence analysis for hypertrophic cardiomyopathy
S3866
Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (hcm) in an individual with a known hcm mutation in the family
S3870
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability



Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A

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