Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 00.03.07x


Attachment:A1

Policy #:00.03.07x

Description:CPT 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.


CURRENT PROCEDURAL TERMINOLOGY (CPT) 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 the monthly capitation fee.
  • The Delete Date indicates either the date the code becomes invalid and/or the date the code is no longer included in the monthly capitation fee.
CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
CPT Code
Effective Date
Delete Date
0001M
9/15/2012
0001U
1/1/2017
0002M
9/15/2012
0002U
1/1/2017
0003M
9/15/2012
0003U
1/1/2017
0004M
7/1/2013
0005M
7/1/2013
0009M
7/1/2015
0010M
7/1/2015
0011M
1/1/2018
0012U
8/1/2017
0016U
8/1/2017
0017U
8/1/2017
0022U
10/1/2017
0023U
10/1/2017
0024U
1/1/2018
0025U
1/1/2018
0026U
1/1/2018
0027U
1/1/2018
0028U
1/1/2018
0029U
1/1/2018
0030T
10/1/2011
0030U
1/1/2018
0031U
1/1/2018
0032U
1/1/2018
0033U
1/1/2018
0034U
1/1/2018
0080U
1/1/2019
0081U
1/1/2019
0082U
1/1/2019
0083U
1/1/2019
0084U
7/1/2019
0085U
7/1/2019
0086U
7/1/2019
0087U
7/1/2019
0088U
7/1/2019
0089U
7/1/2019
0090U
7/1/2019
0091U
7/1/2019
0092U
7/1/2019
0093U
7/1/2019
0094U
7/1/2019
0095U
7/1/2019
0096U
7/1/2019
0097U
7/1/2019
0098U
7/1/2019
0099U
7/1/2019
0100U
7/1/2019
0101U
7/1/2019
0102U
7/1/2019
0103T
10/1/2011
12/31/2015
0103U
7/1/2019
0104U
7/1/2019
10/1/2019
0105U
10/1/2019
0106U
10/1/2019
0107U
10/1/2019
0108U
10/1/2019
0109U
10/1/2019
0110U
10/1/2019
0111T
10/1/2011
0111U
10/1/2019
0112U
10/1/2019
0113U
10/1/2019
0114U
10/1/2019
0115U
10/1/2019
0116U
10/1/2019
0117U
10/1/2019
0118U
10/1/2019
0119U
10/1/2019
0120U
10/1/2019
0121U
10/1/2019
0122U
10/1/2019
0123U
10/1/2019
0124U
10/1/2019
0125U
10/1/2019
0126U
10/1/2019
0127U
10/1/2019
0128U
10/1/2019
0129U
10/1/2019
0130U
10/1/2019
0131U
10/1/2019
0132U
10/1/2019
0133U
10/1/2019
0134U
10/1/2019
0135U
10/1/2019
0136U
10/1/2019
0137U
10/1/2019
0138U
10/1/2019
0279T
1/1/2012
0280T
1/1/2012
0423T
01/01/2016
0500T
01/01/2018


CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
CPT Code
Effective Date
Delete Date
36400
10/01/2011
36405
10/01/2011
36406
10/01/2011
36410
10/01/2011
36415
10/01/2011
36416
10/01/2011
36420
10/01/2011
36425
10/01/2011
80047
10/01/2011
80048
10/01/2011
80050
10/01/2011
80051
10/01/2011
80053
10/01/2011
80055
10/01/2011
80061
10/01/2011
80069
10/01/2011
80074
10/01/2011
80076
10/01/2011
80081
01/01/2016
80100
10/01/2011
12/31/2014
80101
10/01/2011
12/31/2014
80102
10/01/2011
12/31/2014
80103
10/01/2011
12/31/2014
80104
10/01/2011
12/31/2014
80150
10/01/2011
80152
10/01/2011
12/31/2014
80154
10/01/2011
12/31/2014
80155
01/01/2014
80156
10/01/2011
80157
10/01/2011
80158
10/01/2011
80159
01/01/2014
80160
10/01/2011
12/31/2014
80162
10/01/2011
80163
01/01/2015
80164
10/01/2011
80165
01/01/2015
80166
10/01/2011
12/31/2014
80168
10/01/2011
80169
01/01/2014
80170
10/01/2011
80171
01/01/2014
80172
10/01/2011
12/31/2014
80173
10/01/2011
12/31/2014
80174
10/01/2011
80175
01/01/2014
80176
10/01/2011
80177
01/01/2014
80178
10/01/2011
80180
01/01/2014
80182
10/01/2011
12/31/2014
80183
01/01/2014
80184
10/01/2011
80185
10/01/2011
80186
10/01/2011
80188
10/01/2011
80190
10/01/2011
80192
10/01/2011
80194
10/01/2011
80195
10/01/2011
80196
10/01/2011
12/31/2014
80197
10/01/2011
80198
10/01/2011
80199
01/01/2014
80200
10/01/2011
80201
10/01/2011
80202
10/01/2011
80203
01/01/2014
80299
10/01/2011
80300
01/01/2015



12/31/2016
80301
01/01/2015 12/31/2016
80302
01/01/2015 12/31/2016
80303
01/01/2015 12/31/2016
80304
01/01/2015 12/31/2016
80305
01/01/2017
80306
01/01/2017
80307






01/01/2017
80320
01/01/2015
80321
01/01/2015
80322
01/01/2015
80323
01/01/2015
80324
01/01/2015
80325
01/01/2015
80326
01/01/2015
80327
01/01/2015
80328
01/01/2015
80329
01/01/2015
80330
01/01/2015
80331
01/01/2015
80332
01/01/2015
80333
01/01/2015
80334
01/01/2015
80335
01/01/2015
80336
01/01/2015
80337
01/01/2015
80338
01/01/2015
80339
01/01/2015
80340
01/01/2015
80341
01/01/2015
80342
01/01/2015
80343
01/01/2015
80344
01/01/2015
80345
01/01/2015
80346
01/01/2015
80347
01/01/2015
80348
01/01/2015
80349
01/01/2015
80350
01/01/2015
80351
01/01/2015
80352
01/01/2015
80353
01/01/2015
80354
01/01/2015
80355
01/01/2015
80356
01/01/2015
80357
01/01/2015
80358
01/01/2015
80359
01/01/2015
80360
01/01/2015
80361
01/01/2015
80362
01/01/2015
80363
01/01/2015
80364
01/01/2015
80365
01/01/2015
80366
01/01/2015
80367
01/01/2015
80368
01/01/2015
80369
01/01/2015
80370
01/01/2015
80371
01/01/2015
80372
01/01/2015
80373
01/01/2015
80374
01/01/2015
80375
01/01/2015
80376
01/01/2015
80377
01/01/2015
80400
10/01/2011
80402
10/01/2011
80406
10/01/2011
80408
10/01/2011
80410
10/01/2011
80412
10/01/2011
80414
10/01/2011
80415
10/01/2011
80416
10/01/2011
80417
10/01/2011
80418
10/01/2011
80420
10/01/2011
80422
10/01/2011
80424
10/01/2011
80426
10/01/2011
80428
10/01/2011
80430
10/01/2011
80432
10/01/2011
80434
10/01/2011
80435
10/01/2011
80436
10/01/2011
80438
10/01/2011
80439
10/01/2011
80440
10/01/2011
12/31/2014
80500
10/01/2011
80502
10/01/2011

CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
CPT Code
Effective Date
Delete Date
81000
10/01/2011
81001
10/01/2011
81002
10/01/2011
81003
10/01/2011
81005
10/01/2011
81007
10/01/2011
81015
10/01/2011
81020
10/01/2011
81025
10/01/2011
81050
10/01/2011
81099
10/01/2011
81105
01/01/2018
81106
01/01/2018
81107
01/01/2018
81108
01/01/2018
81109
01/01/2018
81110
01/01/2018
81111
01/01/2018
81112
01/01/2018
81120
01/01/2018
81121
01/01/2018
81162
01/01/2016
81163
01/01/2019
81164
01/01/2019
81165
01/01/2019
81166
01/01/2019
81167
01/01/2019
81170
01/01/2016
81171
01/01/2019
81172
01/01/2019
81173
01/01/2019
81174
01/01/2019
81175
01/01/2018
81176
01/01/2018
81177
01/01/2019
81178
01/01/2019
81179
01/01/2019
81180
01/01/2019
81181
01/01/2019
81182
01/01/2019
81183
01/01/2019
81184
01/01/2019
81185
01/01/2019
81186
01/01/2019
81187
01/01/2019
81188
01/01/2019
81189
01/01/2019
81190
01/01/2019
81200
01/01/2012
81201
01/01/2013
81202
01/01/2013
81203
01/01/2013
81204
01/01/2019
81205
01/01/2012
81206
01/01/2012
81207
01/01/2012
81208
01/01/2012
81209
01/01/2012
81210
01/01/2012
81211
01/01/2012



01/01/2019
81212
01/01/2012
81213
01/01/2012
01/01/2019
81214
01/01/2012
01/01/2019
81215
01/01/2012
81216
01/01/2012
81217
01/01/2012
81218
01/01/2016
81219
01/01/2016
81220
01/01/2012
81221
01/01/2012
81222
01/01/2012
81223
01/01/2012
81224
01/01/2012
81225
01/01/2012
81226
01/01/2012
81227
01/01/2012
81228
01/01/2012
81229
01/01/2012
81230
01/01/2018
81231
01/01/2018
81232
01/01/2018
81233
01/01/2019
81234
01/01/2019
81235

01/01/2013
81236
01/01/2019
81237
01/01/2019
81238
01/01/2018
81239
01/01/2019
81240
01/01/2012
81241
01/01/2012
81242
01/01/2012
81243
01/01/2012
81244
01/01/2012
81245
01/01/2012
81246
01/01/2015
81247
01/01/2018
81248
01/01/2018
81249
01/01/2018
81250
01/01/2012
81251
01/01/2012
81252

01/01/2013
81253
01/01/2013
81254
01/01/2013
81255
01/01/2012
81256
01/01/2012
81257
01/01/2012
81258
01/01/2018
81259
01/01/2018
81260
01/01/2012
81261
01/01/2012
81262
01/01/2012
81263
01/01/2012
81264
01/01/2012
81265
01/01/2012
81266
01/01/2012
81267
01/01/2012
81268
01/01/2012
81269
01/01/2018
81270
01/01/2012
81271
01/01/2019
81272
01/01/2016
81273
01/01/2016
81274
01/01/2019
81275
01/01/2012
81276
01/01/2016
81280
01/01/2012
12/31/2016
81281
01/01/2012
12/31/2016
81282
01/01/2012
12/31/2016
81283
01/01/2018
81284
01/01/2019
81285
01/01/2019
81286
01/01/2018
81287
01/01/2014
81288
01/01/2015
81289
01/01/2019
81290
01/01/2012
81291
01/01/2012
81292
01/01/2012
81293
01/01/2012
81294
01/01/2012
81295
01/01/2012
81296
01/01/2012
81297
01/01/2012
81298
01/01/2012
81299
01/01/2012
81300
01/01/2012
81301
01/01/2012
81302
01/01/2012
81303
01/01/2012
81304
01/01/2012
81305
01/01/2019
81306
01/01/2019
81310
01/01/2012
81311
01/01/2016
81312
01/01/2019
81313
01/01/2015
81314
01/01/2016
81315
01/01/2012
81316
01/01/2012
81317
01/01/2012
81318
01/01/2012
81319
01/01/2012
81320
01/01/2019
81321
01/01/2013
81322
01/01/2013
81323
01/01/2013
81324
01/01/2013
81325
01/01/2013
81326
01/01/2013
81327
01/01/2017
81328
01/01/2018
81329
01/01/2019
81330
01/01/2012
81331
01/01/2012
81332
01/01/2012
81333
01/01/2019
81334
01/01/2018
81335
01/01/2018
81336
01/01/2019
81337
01/01/2019
81340
01/01/2012
81341
01/01/2012
81342
01/01/2012
81343
01/01/2019
81344
01/01/2019
81345
01/01/2019
81346
01/01/2018
81350
01/01/2012
81355
01/01/2012
81361
01/01/2018
81362
01/01/2018
81363
01/01/2018
81364
01/01/2018
81370
01/01/2012
81371
01/01/2012
81372
01/01/2012
81373
01/01/2012
81374
01/01/2012
81375
01/01/2012
81376
01/01/2012
81377
01/01/2012
81378
01/01/2012
81379
01/01/2012
81380
01/01/2012
81381
01/01/2012
81382
01/01/2012
81383
01/01/2012

CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
CPT Code
Effective Date
Delete Date
81400
01/01/2012
81401
01/01/2012
81402
01/01/2012
81403
01/01/2012
81404
01/01/2012
81405
01/01/2012
81406
01/01/2012
81407
01/01/2012
81408
01/01/2012
81410
01/01/2015
81411
01/01/2015
81412
01/01/2016
81413




01/01/2017
81414
01/01/2017
81415
01/01/2015
81416
01/01/2015
81417
01/01/2015
81420
01/01/2015
81422
01/01/2017
81425
01/01/2015
81426
01/01/2015
81427
01/01/2015
81430
01/01/2015
81431
01/01/2015
81432
01/01/2016
81433
01/01/2016
81434
01/01/2016
81435
01/01/2015
81436
01/01/2015
81437
01/01/2016
81438
01/01/2016
81439



01/01/2017
81440
01/01/2015
81442
01/01/2016
81443
01/01/2019
81445
01/01/2015
81448
01/01/2018
81450
01/01/2015
81455
01/01/2015
81460
01/01/2015
81465
01/01/2015
81470
01/01/2015
81471
01/01/2015
81479
01/01/2013
81490
01/01/2016
81493
01/01/2016
81500

01/01/2013
81503
01/01/2013
81504
01/01/2014
81506
01/01/2013
81507
01/01/2014
81508
01/01/2013
81509

01/01/2013
81510
01/01/2013
81511
01/01/2013
81512
01/01/2013
81518
01/01/2019
81519
01/01/2015
81520
01/01/2018
81521
01/01/2018
81525
01/01/2016
81528
01/01/2016
81535
01/01/2016
81536
01/01/2016
81538
01/01/2016
81539



01/01/2017
81540
01/01/2016
81541
01/01/2018
81545
01/01/2016
81551
01/01/2018
81595
01/01/2016
81596
01/01/2019
81599
01/01/2013
CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
CPT Code
Effective Date
Delete Date
82000
10/01/2011
12/31/2014
82003
10/01/2011
12/31/2014
82009
10/01/2011
82010
10/01/2011
82013
10/01/2011
82016
10/01/2011
82017
10/01/2011
82024
10/01/2011
82030
10/01/2011
82040
10/01/2011
82042
10/01/2011
82043
10/01/2011
82044
10/01/2011
82045
10/01/2011
82055
10/01/2011
12/31/2014
82075
10/01/2011
82085
10/01/2011
82088
10/01/2011
82101
10/01/2011
12/31/2014
82103
10/01/2011
82104
10/01/2011
82105
10/01/2011
82106
10/01/2011
82107
10/01/2011
82108
10/01/2011
82120
10/01/2011
82127
10/01/2011
82128
10/01/2011
82131
10/01/2011
82135
10/01/2011
82136
10/01/2011
82139
10/01/2011
82140
10/01/2011
82143
10/01/2011
82145
10/01/2011
12/31/2014
82150
10/01/2011
82154
10/01/2011
82157
10/01/2011
82160
10/01/2011
82163
10/01/2011
82164
10/01/2011
82172
10/01/2011
82175
10/01/2011
82180
10/01/2011
82190
10/01/2011
82205
10/01/2011
12/31/2014
82232
10/01/2011
82239
10/01/2011
82240
10/01/2011
82247
10/01/2011
82248
10/01/2011
82252
10/01/2011
82261
10/01/2011
82270
10/01/2011
82271
10/01/2011
82272
10/01/2011
82274
10/01/2011
82286
10/01/2011
82300
10/01/2011
82306
10/01/2011
82308
10/01/2011
82310
10/01/2011
82330
10/01/2011
82331
10/01/2011
82340
10/01/2011
82355
10/01/2011
82360
10/01/2011
82365
10/01/2011
82370
10/01/2011
82373
10/01/2011
82374
10/01/2011
82375
10/01/2011
82376
10/01/2011
82378
10/01/2011
82379
10/01/2011
82380
10/01/2011
82382
10/01/2011
82383
10/01/2011
82384
10/01/2011
82387
10/01/2011
82390
10/01/2011
82397
10/01/2011
82415
10/01/2011
82435
10/01/2011
82436
10/01/2011
82438
10/01/2011
82441
10/01/2011
82465
10/01/2011
82480
10/01/2011
82482
10/01/2011
82485
10/01/2011
82486
10/01/2011
12/31/2015
82487
10/01/2011
12/31/2015
82488
10/01/2011
12/31/2015
82489
10/01/2011
12/31/2015
82491
10/01/2011
12/31/2015
82492
10/01/2011
82495
10/01/2011
82507
10/01/2011
82520
10/01/2011
12/31/2014
82523
10/01/2011
82525
10/01/2011
82528
10/01/2011
82530
10/01/2011
82533
10/01/2011
82540
10/01/2011
82541
10/01/2011
12/31/2015
82542
10/01/2011
82543
10/01/2011
12/31/2015
82544
10/01/2011
12/31/2015
82550
10/01/2011
82552
10/01/2011
82553
10/01/2011
82554
10/01/2011

CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
CPT Code
Effective Date
Delete Date
82565
10/01/2011
82570
10/01/2011
82575
10/01/2011
82585
10/01/2011
82595
10/01/2011
82600
10/01/2011
82607
10/01/2011
82608
10/01/2011
82610
10/01/2011
82615
10/01/2011
82626
10/01/2011
82627
10/01/2011
82633
10/01/2011
82634
10/01/2011
82638
10/01/2011
82642
01/01/2019
82646
10/01/2011
12/31/2014
82649
10/01/2011
12/31/2014
82651
10/01/2011
12/31/2014
82652
10/01/2011
82654
10/01/2011
12/31/2014
82656
10/01/2011
82657
10/01/2011
82658
10/01/2011
82664
10/01/2011
82666
10/01/2011
12/31/2014
82668
10/01/2011
82670
10/01/2011
82671
10/01/2011
82672
10/01/2011
82677
10/01/2011
82679
10/01/2011
82690
10/01/2011
12/31/2014
82693
10/01/2011
82696
10/01/2011
82705
10/01/2011
82710
10/01/2011
82715
10/01/2011
82725
10/01/2011
82726
10/01/2011
82728
10/01/2011
82731
10/01/2011
82735
10/01/2011
82742
10/01/2011
12/31/2014
82746
10/01/2011
82747
10/01/2011
82757
10/01/2011
82759
10/01/2011
82760
10/01/2011
82775
10/01/2011
82776
10/01/2011
82777
01/01/2013
82784
10/01/2011
82785
10/01/2011
82787
10/01/2011
82800
10/01/2011
82803
10/01/2011
82805
10/01/2011
82810
10/01/2011
82820
10/01/2011
82930
10/01/2011
82938
10/01/2011
82941
10/01/2011
82943
10/01/2011
82945
10/01/2011
82946
10/01/2011
82947
10/01/2011
82948
10/01/2011
82950
10/01/2011
82951
10/01/2011
82952
10/01/2011
82953
10/01/2011
12/31/2014
82955
10/01/2011
82960
10/01/2011
82962
10/01/2011
82963
10/01/2011
82965
10/01/2011
82975
10/01/2011
12/31/2014
82977
10/01/2011
82978
10/01/2011
82979
10/01/2011
82980
10/01/2011
12/31/2014
82985
10/01/2011
CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
CPT Code
Effective Date
Delete Date
83001
10/01/2011
83002
10/01/2011
83003
10/01/2011
83006
01/01/2015
83008
10/01/2011
12/31/2014
83009
10/01/2011
83010
10/01/2011
83012
10/01/2011
83013
10/01/2011
83014
10/01/2011
83015
10/01/2011
83018
10/01/2011
83020
10/01/2011
83021
10/01/2011
83026
10/01/2011
83030
10/01/2011
83033
10/01/2011
83036
10/01/2011
83037
10/01/2011
83045
10/01/2011
83050
10/01/2011
83051
10/01/2011
83055
10/01/2011
12/31/2014
83060
10/01/2011
83065
10/01/2011
83068
10/01/2011
83069
10/01/2011
83070
10/01/2011
83071
10/01/2011
12/31/2014
83080
10/01/2011
83088
10/01/2011
83090
10/01/2011
83150
10/01/2011
83491
10/01/2011
83497
10/01/2011
83498
10/01/2011
83499
10/01/2011
12/31/2017
83500
10/01/2011
83505
10/01/2011
83516
10/01/2011
83518
10/01/2011
83519
10/01/2011
83520
10/01/2011
83525
10/01/2011
83527
10/01/2011
83528
10/01/2011
83540
10/01/2011
83550
10/01/2011
83570
10/01/2011
83582
10/01/2011
83586
10/01/2011
83593
10/01/2011
83605
10/01/2011
83615
10/01/2011
83625
10/01/2011
83630
10/01/2011
83631
10/01/2011
83632
10/01/2011
83633
10/01/2011
83634
10/01/2011
12/31/2014
83655
10/01/2011
83661
10/01/2011
83662
10/01/2011
83663
10/01/2011
83664
10/01/2011
83670
10/01/2011
83690
10/01/2011
83695
10/01/2011
83698
10/01/2011
83700
10/01/2011
83701
10/01/2011
83704
10/01/2011
83718
10/01/2011
83719
10/01/2011
83721
10/01/2011
83722
01/01/2019
83727
10/01/2011
83735
10/01/2011
83775
10/01/2011
83785
10/01/2011
83788
10/01/2011
12/31/2015
83789
10/01/2011
83805
10/01/2011
12/31/2014
83825
10/01/2011
83835
10/01/2011
83840
10/01/2011
12/31/2014
83857
10/01/2011
83858
10/01/2011
12/31/2014
83861
10/01/2011
83864
10/01/2011
83866
10/01/2011
12/31/2014
83872
10/01/2011
83873
10/01/2011
83874
10/01/2011
83876
10/01/2011
83880
10/01/2011
83883
10/01/2011
83885
10/01/2011
83887
10/01/2011
12/31/2014
83890
10/01/2011
83891
10/01/2011
83892
10/01/2011
83893
10/01/2011
83894
10/01/2011
83896
10/01/2011
83897
10/01/2011
83898
10/01/2011
83900
10/01/2011
83901
10/01/2011
83902
10/01/2011
83903
10/01/2011
83904
10/01/2011
83905
10/01/2011
83906
10/01/2011
83907
10/01/2011
83908
10/01/2011
83909
10/01/2011
83912
10/01/2011
83913
10/01/2011
83914
10/01/2011
83915
10/01/2011
83916
10/01/2011
83918
10/01/2011
83919
10/01/2011
83921
10/01/2011
83925
10/01/2011
12/31/2014
83930
10/01/2011
83935
10/01/2011
83937
10/01/2011
83945
10/01/2011
83950
10/01/2011
83951
10/01/2011
83970
10/01/2011
CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
CPT Code
Effective Date
Delete Date
83986
10/01/2011
83987
10/01/2011
83992
10/01/2011
83993
10/01/2011
84022
10/01/2011
12/31/2014
84030
10/01/2011
84035
10/01/2011
84060
10/01/2011
84061
10/01/2011
12/31/2017
84066
10/01/2011
84075
10/01/2011
84078
10/01/2011
84080
10/01/2011
84081
10/01/2011
84085
10/01/2011
84087
10/01/2011
84100
10/01/2011
84105
10/01/2011
84106
10/01/2011
84110
10/01/2011
84112
10/01/2011
84119
10/01/2011
84120
10/01/2011
84126
10/01/2011
84127
10/01/2011
12/31/2014
84132
10/01/2011
84133
10/01/2011
84134
10/01/2011
84135
10/01/2011
84138
10/01/2011
84140
10/01/2011
84143
10/01/2011
84144
10/01/2011
84145
10/01/2011
84146
10/01/2011
84150
10/01/2011
84152
10/01/2011
84153
10/01/2011
84154
10/01/2011
84155
10/01/2011
84156
10/01/2011
84157
10/01/2011
84160
10/01/2011
84163
10/01/2011
84165
10/01/2011
84166
10/01/2011
84181
10/01/2011
84182
10/01/2011
84202
10/01/2011
84203
10/01/2011
84206
10/01/2011
84207
10/01/2011
84210
10/01/2011
84220
10/01/2011
84228
10/01/2011
84233
10/01/2011
84234
10/01/2011
84235
10/01/2011
84238
10/01/2011
84244
10/01/2011
84252
10/01/2011
84255
10/01/2011
84260
10/01/2011
84270
10/01/2011
84275
10/01/2011
84285
10/01/2011
84295
10/01/2011
84300
10/01/2011
84302
10/01/2011
84305
10/01/2011
84307
10/01/2011
84311
10/01/2011
84315
10/01/2011
84375
10/01/2011
84376
10/01/2011
84377
10/01/2011
84378
10/01/2011
84379
10/01/2011
84392
10/01/2011
84402
10/01/2011
84403
10/01/2011
84410
01/01/2017
84425
10/01/2011
84430
10/01/2011
84431
10/01/2011
84432
10/01/2011
84436
10/01/2011
84437
10/01/2011
84439
10/01/2011
84442
10/01/2011
84443
10/01/2011
84445
10/01/2011
84446
10/01/2011
84449
10/01/2011
84450
10/01/2011
84460
10/01/2011
84466
10/01/2011
84478
10/01/2011
84479
10/01/2011
84480
10/01/2011
84481
10/01/2011
84482
10/01/2011
84484
10/01/2011
84485
10/01/2011
84488
10/01/2011
84490
10/01/2011
84510
10/01/2011
84512
10/01/2011
84520
10/01/2011
84525
10/01/2011
84540
10/01/2011
84545
10/01/2011
84550
10/01/2011
84560
10/01/2011
84577
10/01/2011
84578
10/01/2011
84580
10/01/2011
84583
10/01/2011
84585
10/01/2011
84586
10/01/2011
84588
10/01/2011
84590
10/01/2011
84591
10/01/2011
84597
10/01/2011
84600
10/01/2011
84620
10/01/2011
84630
10/01/2011
84681
10/01/2011
84702
10/01/2011
84703
10/01/2011
84704
10/01/2011
84830
10/01/2011
84999
10/01/2011
85002
10/01/2011
85004
10/01/2011
85007
10/01/2011
85008
10/01/2011
85009
10/01/2011
85013
10/01/2011
85014
10/01/2011
85018
10/01/2011
85025
10/01/2011
85027
10/01/2011
85032
10/01/2011
85041
10/01/2011
85044
10/01/2011
85045
10/01/2011
85046
10/01/2011
85048
10/01/2011
85049
10/01/2011
85055
10/01/2011
85060
10/01/2011
85097
10/01/2011
85130
10/01/2011
85170
10/01/2011
85175
10/01/2011
85210
10/01/2011
85220
10/01/2011
85230
10/01/2011
85240
10/01/2011
85244
10/01/2011
85245
10/01/2011
85246
10/01/2011
85247
10/01/2011
85250
10/01/2011
85260
10/01/2011
85270
10/01/2011
85280
10/01/2011
85290
10/01/2011
85291
10/01/2011
85292
10/01/2011
85293
10/01/2011
85300
10/01/2011
85301
10/01/2011
85302
10/01/2011
85303
10/01/2011
85305
10/01/2011
85306
10/01/2011
85307
10/01/2011
85335
10/01/2011
85337
10/01/2011
85345
10/01/2011
85347
10/01/2011
85348
10/01/2011
85360
10/01/2011
85362
10/01/2011
85366
10/01/2011
85370
10/01/2011
85378
10/01/2011
85379
10/01/2011
85380
10/01/2011
85384
10/01/2011
85385
10/01/2011
85390
10/01/2011
85396
10/01/2011
85397
10/01/2011
85400
10/01/2011
85410
10/01/2011
85415
10/01/2011
85420
10/01/2011
85421
10/01/2011
85441
10/01/2011
85445
10/01/2011
85460
10/01/2011
85461
10/01/2011
85475
10/01/2011
85520
10/01/2011
85525
10/01/2011
85530
10/01/2011
85536
10/01/2011
85540
10/01/2011
85547
10/01/2011
85549
10/01/2011
85555
10/01/2011

CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
CPT Code
Effective Date
Delete Date
85557
10/01/2011
85576
10/01/2011
85597
10/01/2011
85598
10/01/2011
85610
10/01/2011
85611
10/01/2011
85612
10/01/2011
85613
10/01/2011
85635
10/01/2011
85651
10/01/2011
85652
10/01/2011
85660
10/01/2011
85670
10/01/2011
85675
10/01/2011
85705
10/01/2011
85730
10/01/2011
85732
10/01/2011
85810
10/01/2011
85999
10/01/2011
86000
10/01/2011
86001
10/01/2011
86003
10/01/2011
86005
10/01/2011
86008
0/01/2018
86021
10/01/2011
86022
10/01/2011
86023
10/01/2011
86038
10/01/2011
86039
10/01/2011
86060
10/01/2011
86063
10/01/2011
86077
10/01/2011
86078
10/01/2011
86079
10/01/2011
86140
10/01/2011
86141
10/01/2011
86146
10/01/2011
86147
10/01/2011
86148
10/01/2011
86152
01/01/2013
86153


01/01/2013
86155
10/01/2011
86156
10/01/2011
86157
10/01/2011
86160
10/01/2011
86161
10/01/2011
86162
10/01/2011
86171
10/01/2011
86185
10/01/2011
12/31/2017
86200
10/01/2011
86215
10/01/2011
86225
10/01/2011
86226
10/01/2011
86235
10/01/2011
86243
10/01/2011
12/31/2017
86255
10/01/2011
86256
10/01/2011
86277
10/01/2011
86280
10/01/2011
86294
10/01/2011
86300
10/01/2011
86301
10/01/2011
86304
10/01/2011
86305
10/01/2011
86308
10/01/2011
86309
10/01/2011
86310
10/01/2011
86316
10/01/2011
86317
10/01/2011
86318
10/01/2011
86320
10/01/2011
86325
10/01/2011
86327
10/01/2011
86329
10/01/2011
86331
10/01/2011
86332
10/01/2011
86334
10/01/2011
86335
10/01/2011
86336
10/01/2011
86337
10/01/2011
86340
10/01/2011
86341
10/01/2011
86343
10/01/2011
86344
10/01/2011
86352
10/01/2011
86353
10/01/2011
86355
10/01/2011
86356
10/01/2011
86357
10/01/2011
86359
10/01/2011
86360
10/01/2011
86361
10/01/2011
86367
10/01/2011
86376
10/01/2011
86378
10/01/2011
12/31/2017
86382
10/01/2011
86384
10/01/2011
86386
01/01/2012
86403
10/01/2011
86406
10/01/2011
86430
10/01/2011
86431
10/01/2011
86480
10/01/2011
86481
10/01/2011
86485
10/01/2011
86486
10/01/2011
86490
10/01/2011
86510
10/01/2011
86580
10/01/2011
12/31/2015
86590
10/01/2011
86592
10/01/2011
86593
10/01/2011
86602
10/01/2011
86603
10/01/2011
86606
10/01/2011
86609
10/01/2011
86611
10/01/2011
86612
10/01/2011
86615
10/01/2011
86617
10/01/2011
86618
10/01/2011
86619
10/01/2011
86622
10/01/2011
86625
10/01/2011
86628
10/01/2011
86631
10/01/2011
86632
10/01/2011
86635
10/01/2011
86638
10/01/2011
86641
10/01/2011
86644
10/01/2011
86645
10/01/2011
86648
10/01/2011
86651
10/01/2011
86652
10/01/2011
86653
10/01/2011
86654
10/01/2011
86658
10/01/2011
86663
10/01/2011
86664
10/01/2011
86665
10/01/2011
86666
10/01/2011
86668
10/01/2011
86671
10/01/2011
86674
10/01/2011
86677
10/01/2011
86682
10/01/2011
86684
10/01/2011
86687
10/01/2011
86688
10/01/2011
86689
10/01/2011
86692
10/01/2011
86694
10/01/2011
86695
10/01/2011
86696
10/01/2011
86698
10/01/2011
86701
10/01/2011
86702
10/01/2011
86703
10/01/2011
86704
10/01/2011
86705
10/01/2011
86706
10/01/2011
86707
10/01/2011
86708
10/01/2011
86709
10/01/2011
86710
10/01/2011
86711
01/01/2013
86713
10/01/2011
86717
10/01/2011
86720
10/01/2011
86723
10/01/2011
86727
10/01/2011
86729
10/01/2011
12/31/2017
86732
10/01/2011
86735
10/01/2011
86738
10/01/2011
86741
10/01/2011
86744
10/01/2011
86747
10/01/2011
86750
10/01/2011
86753
10/01/2011
86756
10/01/2011
86757
10/01/2011
86759
10/01/2011
86762
10/01/2011
86765
10/01/2011
86768
10/01/2011
86771
10/01/2011
86774
10/01/2011
86777
10/01/2011
86778
10/01/2011
86780
10/01/2011
86784
10/01/2011
86787
10/01/2011
86788
10/01/2011
86789
10/01/2011
86790
10/01/2011
86793
10/01/2011
86794
01/01/2018
86800
10/01/2011
86803
10/01/2011
86804
10/01/2011
86805
10/01/2011
86806
10/01/2011
86807
10/01/2011
86808
10/01/2011
86812
10/01/2011
86813
10/01/2011
86816
10/01/2011
86817
10/01/2011
86821
10/01/2011
86822
10/01/2011
12/31/2017
86825
10/01/2011
86826
10/01/2011
86828



01/01/2013
86829



01/01/2013
86830


01/01/2013
86831


01/01/2013
86832


01/01/2013
86833
01/01/2013
86834
01/01/2013
86835
01/01/2013
86849
10/01/2011
86850
10/01/2011
86860
10/01/2011
86870
10/01/2011
86880
10/01/2011
86885
10/01/2011

CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
CPT Code
Effective Date
Delete Date
86886
10/01/2011
86890
10/01/2011
86891
10/01/2011
86900
10/01/2011
86901
10/01/2011
86902
10/01/2011
86904
10/01/2011
86905
10/01/2011
86906
10/01/2011
86910
10/01/2011
86911
10/01/2011
86920
10/01/2011
86921
10/01/2011
86922
10/01/2011
86923
10/01/2011
86927
10/01/2011
86930
10/01/2011
86931
10/01/2011
86932
10/01/2011
86940
10/01/2011
86941
10/01/2011
86945
10/01/2011
86950
10/01/2011
86960
10/01/2011
86965
10/01/2011
86970
10/01/2011
86971
10/01/2011
86972
10/01/2011
86975
10/01/2011
86976
10/01/2011
86977
10/01/2011
86978
10/01/2011
86985
10/01/2011
86999
10/01/2011
87001
10/01/2011
12/31/2014
87003
10/01/2011
87015
10/01/2011
87040
10/01/2011
87045
10/01/2011
87046
10/01/2011
87070
10/01/2011
87071
10/01/2011
87073
10/01/2011
87075
10/01/2011
87076
10/01/2011
87077
10/01/2011
87081
10/01/2011
87084
10/01/2011
87086
10/01/2011
87088
10/01/2011
87101
10/01/2011
87102
10/01/2011
87103
10/01/2011
87106
10/01/2011
87107
10/01/2011
87109
10/01/2011
87110
10/01/2011
87116
10/01/2011
87118
10/01/2011
87140
10/01/2011
87143
10/01/2011
87147
10/01/2011
87149
10/01/2011
87150
10/01/2011
87152
10/01/2011
87153
10/01/2011
87158
10/01/2011
87164
10/01/2011
87166
10/01/2011
87168
10/01/2011
87169
10/01/2011
87172
10/01/2011
87176
10/01/2011
87177
10/01/2011
87181
10/01/2011
87184
10/01/2011
87185
10/01/2011
87186
10/01/2011
87187
10/01/2011
87188
10/01/2011
87190
10/01/2011
87197
10/01/2011
87205
10/01/2011
87206
10/01/2011
87207
10/01/2011
87209
10/01/2011
87210
10/01/2011
87220
10/01/2011
87230
10/01/2011
87250
10/01/2011
87252
10/01/2011
87253
10/01/2011
87254
10/01/2011
87255
10/01/2011
87260
10/01/2011
87265
10/01/2011
87267
10/01/2011
87269
10/01/2011
87270
10/01/2011
87271
10/01/2011
87272
10/01/2011
87273
10/01/2011
87274
10/01/2011
87275
10/01/2011
87276
10/01/2011
87277
10/01/2011
12/31/2017
87278
10/01/2011
87279
10/01/2011
87280
10/01/2011
87281
10/01/2011
87283
10/01/2011
87285
10/01/2011
87290
10/01/2011
87299
10/01/2011
87300
10/01/2011
87301
10/01/2011
87305
10/01/2011
87320
10/01/2011
87324
10/01/2011
87327
10/01/2011
87328
10/01/2011
87329
10/01/2011
87332
10/01/2011
87335
10/01/2011
87336
10/01/2011
87337
10/01/2011
87338
10/01/2011
87339
10/01/2011
87340
10/01/2011
87341
10/01/2011
87350
10/01/2011
87380
10/01/2011
87385
10/01/2011
87389
01/01/2012
87390
10/01/2011
87391
10/01/2011
87400
10/01/2011
87420
10/01/2011
87425
10/01/2011
87427
10/01/2011
87430
10/01/2011
87449
10/01/2011
87450
10/01/2011
87451
10/01/2011
87470
10/01/2011
12/31/2017
87471
10/01/2011
87472
10/01/2011
87475
10/01/2011
87476
10/01/2011
87477
10/01/2011
12/31/2017
87480
10/01/2011
87481
10/01/2011
87482
10/01/2011
87483
01/01/2017
87485
10/01/2011
87486
10/01/2011
87487
10/01/2011
87490
10/01/2011
87491
10/01/2011
87492
10/01/2011
87493
10/01/2011
87495
10/01/2011
87496
10/01/2011
87497
10/01/2011
87498
10/01/2011
87500
10/01/2011
87501
10/01/2011
87502
10/01/2011
87503
10/01/2011
87505
01/01/2015
87506
01/01/2015
87507
01/01/2015
87510
10/01/2011
87511
10/01/2011
87512
10/01/2011
87515
10/01/2011
12/31/2017
87516
10/01/2011
87517
10/01/2011
87520
10/01/2011
87521
10/01/2011
87522
10/01/2011
87525
10/01/2011
87526
10/01/2011
87527
10/01/2011
87528
10/01/2011
87529
10/01/2011
87530
10/01/2011
87531
10/01/2011
87532
10/01/2011
87533
10/01/2011
87534
10/01/2011
87535
10/01/2011
87536
10/01/2011
87537
10/01/2011
87538
10/01/2011
87539
10/01/2011
87540
10/01/2011
87541
10/01/2011
87542
10/01/2011
87550
10/01/2011
87551
10/01/2011
87552
10/01/2011
87555
10/01/2011
87556
10/01/2011
87557
10/01/2011
87560
10/01/2011
87561
10/01/2011
87562
10/01/2011
87580
10/01/2011
87581
10/01/2011
87582
10/01/2011
87590
10/01/2011
87591
10/01/2011
87592
10/01/2011
87620
10/01/2011
12/31/2014
87621
10/01/2011
12/31/2014
87622
10/01/2011
12/31/2014
87623
01/01/2015
87624
01/01/2015
87625
01/01/2015
87631




01/01/2013
87632
01/01/2013
87633
01/01/2013
87634
01/01/2018
87640
10/01/2011
87641
10/01/2011
87650
10/01/2011

CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
CPT Code
Effective Date
Delete Date
87651
10/01/2011
87652
10/01/2011
87653
10/01/2011
87660
10/01/2011
87661
01/01/2014
87662
01/01/2018
87797
10/01/2011
87798
10/01/2011
87799
10/01/2011
87800
10/01/2011
87801
10/01/2011
87802
10/01/2011
87803
10/01/2011
87804
10/01/2011
87806
01/01/2015
87807
10/01/2011
87808
10/01/2011
87809
10/01/2011
87810
10/01/2011
87850
10/01/2011
87880
10/01/2011
87899
10/01/2011
87900
10/01/2011
87901
10/01/2011
87902
10/01/2011
87903
10/01/2011
87904
10/01/2011
87905
10/01/2011
87906
10/01/2011
87910
01/01/2013
87912
01/01/2013
87999
10/01/2011
88000
10/01/2011
88005
10/01/2011
88007
10/01/2011
88012
10/01/2011
88014
10/01/2011
88016
10/01/2011
88020
10/01/2011
88025
10/01/2011
88027
10/01/2011
88028
10/01/2011
88029
10/01/2011
88036
10/01/2011
88037
10/01/2011
88040
10/01/2011
88045
10/01/2011
88099
10/01/2011
88104
10/01/2011
88106
10/01/2011
88107
10/01/2011
12/31/2011
88108
10/01/2011
88112
10/01/2011
88120
10/01/2011
88121
10/01/2011
88125
10/01/2011
88130
10/01/2011
88140
10/01/2011
88141
10/01/2011
88142
10/01/2011
88143
10/01/2011
88147
10/01/2011
88148
10/01/2011
88150
10/01/2011
88152
10/01/2011
88153
10/01/2011
88154
10/01/2011
12/31/2017
88155
10/01/2011
88160
10/01/2011
88161
10/01/2011
88162
10/01/2011
88164
10/01/2011
88165
10/01/2011
88166
10/01/2011
88167
10/01/2011
88172
10/01/2011
88173
10/01/2011
88174
10/01/2011
88175
10/01/2011
88177
10/01/2011
88182
10/01/2011
88184
10/01/2011
88185
10/01/2011
88187
10/01/2011
88188
10/01/2011
88189
10/01/2011
88199
10/01/2011
88230
10/01/2011
88233
10/01/2011
88235
10/01/2011
88237
10/01/2011
88239
10/01/2011
88240
10/01/2011
88241
10/01/2011
88245
10/01/2011
88248
10/01/2011
88249
10/01/2011
88261
10/01/2011
88262
10/01/2011
88263
10/01/2011
88264
10/01/2011
88267
10/01/2011
88269
10/01/2011
88271
10/01/2011
88272
10/01/2011
88273
10/01/2011
88274
10/01/2011
88275
10/01/2011
88280
10/01/2011
88283
10/01/2011
88285
10/01/2011
88289
10/01/2011
88291
10/01/2011
88299
10/01/2011
88300
10/01/2011
88302
10/01/2011
88304
10/01/2011
88305
10/01/2011
88307
10/01/2011
88309
10/01/2011
88311
10/01/2011
88312
10/01/2011
88313
10/01/2011
88314
10/01/2011
88318
10/01/2011
12/31/2011
88319
10/01/2011
88321
10/01/2011
88323
10/01/2011
88325
10/01/2011
88329
10/01/2011
88331
10/01/2011
88332
10/01/2011
88333
10/01/2011
88334
10/01/2011
88341
01/01/2015
88342
10/01/2011
88343



01/01/2014
12/31/2014
88344
01/01/2015
88346
10/01/2011
88347
10/01/2011
12/31/2015
88348
10/01/2011
88349
10/01/2011
12/31/2014
88350
01/01/2016
88355
10/01/2011
88356
10/01/2011
88358
10/01/2011
88360
10/01/2011
88361
10/01/2011
88362
10/01/2011
88363
10/01/2011
88364
01/01/2015
88365
10/01/2011
88366
01/01/2015
88367
10/01/2011
88368
10/01/2011
88369
01/01/2015
88371
10/01/2011
88372
10/01/2011
88373
01/01/2015
88374
01/01/2015

88375
01/01/2013
88377
01/01/2015
88380
10/01/2011
88381
10/01/2011
88384
10/01/2011
88385
10/01/2011
88386
10/01/2011
88387
10/01/2011
88388
10/01/2011
88399
10/01/2011
88720
10/01/2011
88738
10/01/2011
88740
10/01/2011
88741
10/01/2011
88749
10/01/2011
89049
10/01/2011
89050
10/01/2011
89051
10/01/2011
89055
10/01/2011
89060
10/01/2011
89125
10/01/2011
89160
10/01/2011
89190
10/01/2011
89220
10/01/2011
89230
10/01/2011
89240
10/01/2011
89250
10/01/2011
89251
10/01/2011
89253
10/01/2011
89254
10/01/2011
89255
10/01/2011
89257
10/01/2011
89258
10/01/2011
89259
10/01/2011
89260
10/01/2011
89261
10/01/2011
89264
10/01/2011
89268
10/01/2011
89272
10/01/2011
89280
10/01/2011
89281
10/01/2011
89290
10/01/2011
89291
10/01/2011
89300
10/01/2011
89310
10/01/2011
89320
10/01/2011
89321
10/01/2011
89322
10/01/2011
89325
10/01/2011
89329
10/01/2011
89330
10/01/2011
89331
10/01/2011
89335
10/01/2011
89342
10/01/2011
89343
10/01/2011
89344
10/01/2011
89346
10/01/2011
89352
10/01/2011
89353
10/01/2011
89354
10/01/2011
89356
10/01/2011
89398
10/01/2011
99000
10/01/2011
99001
10/01/2011
Version Effective Date: 10/01/2019
Version Issued Date: 10/24/2019
Version Reissued Date: N/A

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2017 Independence Blue Cross.
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.