Notification



Notification Issue Date:



Claim Payment Policy


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

Policy #:00.03.07v

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



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.
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


Company Benefit Contracts.




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

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

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

00.03.07v
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

00.03.07u
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

00.03.07t
12/01/2017This policy will become effective 12/01/2017.
This policy has been expanded to include Physician Assistants (PAs) to be eligible to perform services in a specialty group.

00.03.07s
10/01/2017This 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 10/01/2017: 0022U, 0023U

00.03.07r
08/21/2017 (retro effective to 08/01/2017)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

00.03.07q
08/01/2017Revised policy number 00.03.07q was issued as a result of a provider networking initiative. The adoptable source for this policy is Provider Contracting.
Participating 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.

00.03.07p
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

00.03.07o
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 been revised in this policy, effective 01/01/2017:
83015, 83018, 83704, 87147, 87197, 87253

00.03.07n:
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

00.03.07m
01/01/2016The following CPT code has been termed from this policy, effective 12/31/2015: 86580

Per Steering committee, decision was made to term from 00.03.07m and add to 00.10.01v: 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.

00.03.07l
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

00.03.07k
03/01/2015Policy 00.03.07j has been revised. The policy will be reissued as 00.03.07k 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.

00.03.07j
01/01/2015Policy # 00.03.07i has been identified for the 2015 annual CPT code update. The policy will be reissued as 00.03.07j.

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

00.03.07i
12/10/2014Claim payment policy 00.03.07i has been updated to reflect an approved HMO Network Steering Committee change, and has been re-issued as policy 00.03.07i.

The following procedure code has been added as a new exception to a Cardiologist in the office place-of-service effective 12/10/2014, the change is reflected on Att B1: 83880

00.03.07h
07/01/2014Policy # 00.03.07h has been identified for the July 1, 2014 quarterly code update. The policy will be reissued as 00.03.07e.

The following CPT codes have been added to Attachment A1 of the policy:
0006M, 0007M, 0008M

In addition, this policy has been identified for the CPT code update, effective 01/01/2014.

The following CPT codes have been added to this policy: G0461, G0462

00.03.07g
02/01/2014Revised policy number 00.03.07g issued as a result of provider inquiries. The policy was updated to be consistent with current template wording and format.

Management recommend that we move forward and open up the network laboratory rules to allow payment for cpt code 83861 to an Ophthalmologists and optometrists.

Additional table has been added to attachement B1 to address Ophthalmology, Pediatric Ophthalmology and Optometry for cpt code 83861.

In addition, this policy has been identified for the CPT code update, effective 01/01/2014.

The following CPT codes have been added to this policy:
80155, 80159, 80169, 80171, 80175, 80177, 80180, 80183, 80199, 80203, 81287, 81504

00.03.07f
07/31/2013Claim payment policy 00.03.07d has been updated to reflect an approved HMO Network Steering Committee change, and has been re-issued as policy 00.03.07e. A 30-day Notification will be posted on 07/01/2013.

The following procedure code has been added as a new exception to All Non-Capitated Professional Providers in the office place-of-service effective 07/31/2013, the change is reflected on Att B1: 86580

The following procedure code/modifier combination has been added as a new exception to Dermatologist in the office place-of-service effective 07/31/2013, the change is reflected on Att B1: 88331-59

00.03.07e
07/01/2013Policy # 00.03.07d has been identified for the July 1, 2013 quarterly code update. The policy will be reissued as 00.03.07e.

ADDITIONS:
The following CPT codes have been added to Attachment A1 of the policy:
0004M, 0005M

00.03.07d
01/01/2013This policy has been identified for the annual CPT/HCPCS code update, effective 01/01/2013.

ADDITIONS:
The following CPT codes have been added to Attachment A1 of the policy:
81201, 81202, 81203, 81235, 81252, 81253, 81254, 81321, 81322, 81323, 81324, 81325, 81326, 81479, 81500, 81503, 81506, 81508, 81509, 81510, 81511, 81512, 81599, 82777, 86152, 86153, 86711, 86828, 86829, 86830, 86831, 86832, 86832, 86833, 86834, 86835, 87631, 87632, 87633, 87910, 87912, 88375

The following HCPCS codes have been added to Attachment A2 of the policy:
G0452, G0455

00.03.07c
09/15/2012Policy # 00.03.07b has been identified for an Adhoc code update, effective September 15, 2012. The policy will be reissued as 00.03.07c.

ADDITIONS:
The following CPT codes have been added to Attachment A1 of the policy:
0001M, 0002M, 0003M

00.03.07b
04/01/2012Policy # 00.03.07a has been identified for the quarterly HCPCS code update, effective 04/01/2012. The policy will be reissued as 00.03.07b.

The following HCPCS code has been added to Attachment A2:
S3721 - Prostate cancer antigen 3 (PCA3) testing

The following HCPCS codes have been deleted from Attachment A2:
S3711, S3713, S3818, S3819, S3820, S3822, S3823, S3828, S3829, S3830, S3831, S3835, S3837, S3843, S3847, S3848, S3851, S3860, S3862

00.03.07a
01/01/2012Policy # 00.03.07 has been identified for the annual CPT/HCPCS code update, effective 01/01/2012. The policy will be reissued as 00.03.07a.

The following CPT codes have been added to Attachment A1:

0279T, 0280T, 81200, 81205, 81206, 81207, 81208, 81209, 81210, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81240, 81241, 81242, 81243, 81244, 81245, 81250, 81251, 81255, 81256, 81257, 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81270, 81275, 81280, 81281, 81282, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81310, 81315, 81316, 81317, 81318, 81319, 81330, 81331, 81332, 81340, 81341, 81342, 81350, 81355, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 86386, 87389

The following HCPCS code has been added to Attachment A2:
S3722: Dose optimization by area under the curve (auc) analysis, for infusional 5-fluorouracil

The following CPT codes have been deleted from Attachment A1:
88107, 88318

The following CPT code narratives have been revised in Attachment A1:
86703, 88312, 88313, 88314, 88319, P9603, P9604, S3601

00.03.07
10/01/2011This is a new policy. Claim Payment Policy # 00.03.07 was developed to document and communicate the Company's reimbursement position for laboratory services for members enrolled in Health Maintenace Organization or Health Maintenance Organization Point-of-Service products.

A 90-day Notification was posted on 7/1/2011.
Version Effective Date: 01/01/2019
Version Issued Date: 02/18/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.