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PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
00.01.25bt

Policy

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 policy applies to providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Preferred Provider Organization (PPO) Company products.

The PPO Network Rules and Limited Circumstances are as follows:

DURABLE MEDICAL EQUIPMENT RULES AND LIMITED CIRCUMSTANCES
  • Durable medical equipment (DME) (which includes prosthetics and orthotics) under the PPO benefit program (DME Network Rules and Limited Circumstances, Attachments A1 and A2) is considered eligible for payment in an office, in an outpatient setting, and in a home setting, when supplied by an ancillary provider with the DME specialty, such as DME and pharmacy/DME.
  • The limited circumstances of DME services that a participating specialist (this includes certified registered nurse practitioners [CRNPs] and physician assistants [PAs] practicing within these specialty groups), other than a DME provider, may provide, and for which the provider may be eligible for reimbursement, are listed in Attachment A3. Refer to Attachment A3 for the specific provider specialties and eligible codes.
  • All other provider specialties are considered ineligible to provide DME/prosthetic/orthotic equipment, unless otherwise identified by specialty and code in attachment A3.
LABORATORY RULES AND LIMITED CIRCUMSTANCES
  • Laboratory services under the PPO benefit program are determined by the Bureau of Laboratories, and defined by the Pennsylvania Department of Health. For the PPO line of business, all laboratory services listed in Attachment B1 of this policy are considered eligible for payment in an office or outpatient setting, when performed by any type of participating PPO provider. Laboratory services listed in Attachment B2.1 or B2.2 of this policy are only eligible for payment when performed by an independent or a physiological laboratory.
  • The limited circumstances of laboratory services that a participating specialist (this includes CRNPs and PAs practicing within these specialty groups), other than an independent or a physiological laboratory, may provide, and for which the provider may be eligible for reimbursement, are listed in Attachment B3 of this policy.
  • All other provider specialties are considered ineligible to provide laboratory services, unless otherwise identified by specialty and code in attachment B3.
RADIOLOGY RULES AND LIMITED CIRCUMSTANCES
  • Radiology services under the PPO benefit program (Radiology Network Rules and Limited Circumstances, Attachment C1) are considered eligible for payment in an outpatient and office setting when performed by a radiologist or pediatric radiologist at a contracted radiology site.
  • The limited circumstances of radiology services that a participating specialist (this includes CRNPs and PAs practicing within these specialty groups), other than a radiology provider, may provide, and for which the provider may be eligible for reimbursement, are listed in Attachment C2. Refer to attachment C2 for the specific provider specialties and eligible codes.
  • All other provider specialties are considered ineligible to provide radiology services, unless otherwise identified by specialty and code in attachment C2.
PHYSICAL MEDICINE AND REHABILITATIVE RULES AND LIMITED CIRCUMSTANCES
  • Physical medicine and rehabilitative services under the PPO benefit program (Physical Medicine and Rehabilitation Network Rules and Limited Circumstances, Attachment D) are considered eligible for payment in an office and outpatient setting, when performed by a physical therapist at a contracted physical therapy site.
  • The limited circumstances of physical medicine and rehabilitative services that a participating specialist (this includes CRNPs and PAs practicing within these specialty groups), other than a physical therapist provider, and for which the provider may be eligible for reimbursement, are also listed in Attachment D. Refer to Attachment D for the specific provider specialties and eligible codes.
  • All other provider specialties are considered ineligible to provide physical medicine and rehabilitative services, unless otherwise identified by specialty and code in Attachment D.
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.

BILLING REQUIREMENTS

Services performed in the outpatient setting are subject to facility global payment rules. The presence of a code on the exception list 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.

Inclusion of a code in this policy does not imply coverage. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.

Guidelines

MANDATES

For members enrolled in New Jersey products,  refer to the applicable Orthotic and Prosthetic mandate.

Description

This Network Rules policy documents the Company’s reimbursement position for participating Preferred Provider Organization (PPO) professional and ancillary providers who supply durable medical equipment (DME) and perform laboratory, radiology, and physical medicine and rehabilitative services. This policy addresses these services provided in the office or outpatient settings, in the home setting for DME, and at an independent laboratory for laboratory services. The Network Rules policy identifies the specific provider specialties that are eligible for payment when billing Current Procedural Terminology (CPT) or Healthcare Common Procedural Coding System (HCPCS) codes within the four service or equipment types, as defined below:
  • DME (which includes prosthetics and orthotics) refers to equipment and/or a device that meets the following identified criteria:
    • DME criteria:
      • It is durable and can withstand repeated use.
      • It is medical equipment, meaning it is primarily and customarily used to serve a medical purpose.
      • It generally is not useful to an individual in the absence of an illness or injury.​
      • It is appropriate for use in the home.
    • Prosthetics criteria:
      • Prosthetics are devices that replace all or part of either of the following:
        • An absent body organ, including contiguous tissue
        • The function of a permanent inoperative or malfunctioning body organ
    • Orthotics criteria:
      • Orthotics are fabricated or fitted braces or supports (in some cases custom) that are designed to provide alignment/correction in or prevention of neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity.
  • Laboratory services are tests that are performed on biological specimens in order to obtain information about an individual’s health. These tests, which involve measurements, are conducted under controlled conditions.
  • Radiology services encompass the scientific discipline of medical imaging, which utilizes ionization radiation, radionuclides, magnetic resonance, and ultrasound.
  • Physical medicine and rehabilitative care services consist of the combined use of medical, physical, social, technological, educational, and vocational services that enable individuals with disabilities or impairments resulting from disease, injury, prior therapeutic intervention, or congenital anomaly to achieve the highest possible level of functional ability and/or independence in activities of daily living.
Network Rules for provision of specialty services include limited circumstances when participating PPO professional and ancillary providers, other than the designated specialty providers, may be eligible for payment for the provision of certain specialty services. These limited circumstances are identified by specific selected procedures that are eligible when billed by providers with specific specialties in an office or outpatient setting.

References

Agency for Healthcare Research and Quality (AHRQ). Vision rehabilitation for elderly individuals with low vision or blindness.
https://www.cms.gov/Medicare/Coverage/InfoExchange/downloads/rtcvisionrehab.pdf. Accessed April 1, 2024.

American Optometric Association. Low vision. https://www.aoa.org/patients-and-public/caring-for-your-vision/low-vision. Accessed April 1, 2024. 

Company Provider Contracts.​
ICD-10-CM Official Guidelines for Coding and Reporting FY 2019. Low Vision Rehabilitation.
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf. Accessed April 1, 2024.​

Coding

CPT Procedure Code Number(s)
See Attachments.
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
See Attachment D.
HCPCS Level II Code Number(s)
See Attachments.
Revenue Code Number(s)
N/A




Coding and Billing Requirements

Policy History

Revisions From 00.01.25bt:

10/01/2025

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2025. 

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

A4288, E0150, E0658, E0659, L1007, L5657, L6034, L6035, L6036, L6038, L6039, 0575U, 0576U, 0577U, 0578U, 0579U, 0580U, 0581U, 0582U, 0583U, 0584U, 0585U, 0586U, 0587U, 0588U, 0589U, 0590U, 0591U, 0592U, 0593U, 0594U, 0595U, 0596U, 0597U, 0598U, and 0599U

​
The following CPT and HCPCS code narratives have been revised in this policy:

E0765, E0986, L5673, L5679, L5783, L6028, and L7406


Revisions From 00.01.25bs:

04/01/2025

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2025. 

The following CPT/HCPCS codes have been deleted from this policy: 

​A9155, L8010, S4988, 0500T, and 0564T


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

A9154, E0201, E1022, E1023, E1032, E1033, E1034, G0566, G0567, L0720, L1933, L1952, L5827, L6028, L6029, L6030, L6031, L6032, L6033, L6037, L6700, L7406, 0531U, 0532U, 0533U, 0534U, 0535U, 0536U, 0537U, 0538U, 0539U, 0540U, 0541U, 0542U, 0543U, 0544U, 0545U, 0546U, 0547U, 0548U, 0549U, 0550U, and 0551U

​
The following CPT and HCPCS code narratives have been revised in this policy

A4453, A4459, E1028, E1801, E1811, E1816, E1818, E1841, L1932, L1951, L1971, L6692, and L6698​


Revisions From 00.01.25br:

01/01/2025

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2025. 

The following CPT codes have been deleted from this policy: 

81433, 81436, 81438, 86327, 86490, 0346U, 0352U, 0380U, 0428U, 0448U, 0500T, 

93890, 88388.



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

76014, 76015, 76016, 76017, 76018, 76019, 93896, 93897, 93898, G0562, 

81515, 87626, E1803, E1804, E1807, E1808, E1813, E1814, E1822, E1823, E1826, E1827, E1828, E1829.​



The following CPT and HCPCS code narratives have been revised in this policy:

81432, 81435, 81437, 0095U, 0365U, 87624, 88387, 93893, E1800, E1805, E1810, E1815, E1825, E1830.


Revisions From 00.01.25bq:

12/16/2024

This version of the policy will become effective 12/16/2024. Policy number 00.01.25bq is being issued to introduce a radiology network rule exception allowing reimbursement for Dual-Energy X-ray Absorptiometry (DXA), when performed in the office setting by Nuclear Medicine specialty. In addition, Transrectal Ultrasound is being introduced as a radiology network rule exception allowing reimbursement when performed in the office setting by Urology specialty, as identified in this policy.


Nuclear Medicine specialty has been added to the following codes in Attachment C2:


77080, 77081,77085 and 77086


In addition, Urology specialty has been added to the following codes in Attachment C2:

76872

Revisions From 00.01.25bp:

10/01/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2024. 


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


0476U, 0477U, 0478U, 0483U, 0484U, 0485U, 0486U, 0487U, 0488U, 0489U, 
0490U, 0491U, 0492U, 0495U, 0496U, 0497U, 0498U, 0499U, 0500U, 0501U, 
0502U, 0504U, 0505U, 0506U, 0507U, 0510U, 0511U, 0512U, 0513U, 0514U, and 
0515U in Attachment B2.1


E2513 in Attachment A1


L1006, L1653, L1821, L8720, and L8721 in Attachment A2

The following CPT and HCPCS code narratives have been revised in this policy:


0248U, 0403U, E0739, L1652, L1820​


Revisions From 00.01.25bo:

07/01/2024

This version of the policy will become effective 07/01/2024.  


This policy is being issued to introduce a radiology network rule exception that allows reimbursement for ophthalmic ultrasounds when performed in the​ office setting by an optometry specialist, as indicated in the policy.  

​

The optometry provider type has been added to the following codes in Attachment C2:


76510, 76511, 76512, 76513, 76516, 76519, 76529


Revisions From 00.01.25bn:

04/01/2024

This version of the policy will be issued on 04/19/2024 with a retroactive effective date of 04/01/2024. Policy number 00.01.25bn is being issued to introduce a radiology network rule exception allowing reimbursement for doppler ultrasounds when performed in the office setting by Pediatric Cardiology ​providers, as identified in this policy.  ​

 

Pediatric Cardiology provider type has been added to the following codes in Attachment C2:


​76820 and 76821


In addition, this policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2024. 

The following HCPCS codes have been added to this policy:

0439U, 0440U, 0441U, 0442U, 0443U, 0444U, 0445U, 0446U, 0447U, 0448U and

0449U, A4564, A4593, A4594, E0152, E0468, E0736, E0739, E2104, E2298, K1037, L1320, L5783, L5841, S4988 and S9002


​The following HCPCS codes have been deleted from this policy: 
 

0354U, 0416U and E2300


The following HCPCS code narratives have been revised this policy:

A4561 and E2001


Revisions From 00.01.25bm:

01/01/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2024. 

The following CPT codes have been deleted from this policy: 
 
K1001, K1002, K1003, K1005, K1006, K1009, K1013, K1020, K1023, K1024, K1025, K1026, 74710.

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

0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0427U, 0428U, 0429U, 0430U, 0431U, 0432U, 0433U, 0434U, 0435U, 0436U, 0437U, 0438U 81457, 81458, 81459, 81462, 81463, 81464, 81517, 82166, 86041, 86042, 86043, 86366, 0827T, 0828T, 0829T, 0830T, 0831T, 0832T, 0833T, 0834T, 0835T, 0836T, 0837T, 0838T, 0839T, 0840T, 0841T, 0842T, 0843T, 0844T, 0845T, 0846T, 0847T, 0848T, 0849T, 0850T, 0851T, 0852T, 0853T, 0854T, 0855T, 0856T, 87523, 75580, 76987, 76988, 0815T, 0857T, 0865T, 0866T, A4287, A4457, A4540, A7023, E0530, E0680, E0678, E0679, E0681, E0682, E0732, E0735, E1301, E2001, E3000.


The following CPT & HCPCS code narratives have been revised in this policy:

A6531, A6532, A6545


Revisions From 00.01.25bl:

10/01/2023​

This policy has been identified and updated for the CPT/HCPCS code update effective 10/1/2023. 

The following CPT code has been deleted from this policy:  
0386U

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

0019M, 0403U, 0404U, 0405U, 0406U, 0407U, 0409U, 0410U, 0411U, 0413U, 

0414U, 0416U, 0417U, 0418U, B4148, K1036


The following CPT & HCPCS code narratives have been revised in this policy: 
0269U, 0271U, 0272U, 0274U, 0278U, A4344 and K1004

In addition, the following  HCPCS codes have been added to this policy as a result of the 4/1/2023 Quarterly Code Updates:​

A4341, A4342, A4560, A6590, A6591, A7049, E0677, E0711, E1905, K1035, L8678​​


Revisions From 00.01.2bk:

09/25/2023​

This version of the policy will become effective 09/25/2023. This policy number 00.01.25bk​​ has been updated to introduce a radiology network rule exception to allow reimbursement consideration by the Company when performed in the office setting by Nurse Midwife specialty, as identified in this policy.


Nurse Midwife provider type has been added to the following codes in Attachment C2:  

S8055, 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817,  

76825, 76826, 76827, 76828, 76830, 76831, 76856, 76857, 76999​


In addition, the following CPT code has been removed from the Physical Medicine and Rehabilitation Network Rules and Limited Circumstances, Attachment D​ of this policy.

97610​​


Revisions From 00.01.25bj:

04/01/2023

This version of the policy will become effective 04/01/2023. This policy has been updated to introduce a lab network rule exception for Respiratory Syncytial Virus (RSV) and Streptococcus services​​ to all provider specialty types when performed in the office setting.

The following CPT codes have been added to Attachment B1 of this policy: 

87634, 87651 and 87807 


In addition, this policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2023


The following CPT codes have been deleted from this policy: 
G2023, G2024, U0003, U0004 and U0005


The following CPT codes have been added to this policy:  

0364U, 0365U, 0366U, 0367U, 0368U, 0370U, 0371U, 0372U, 0373U, 0374U, 

0375U, 0376U, 0379U, 0380U, 0381U, 0384U, 0385U, 0386U


The following CPT code narratives have been revised in this policy: 
0022U 0095U and A4628​


Revisions From 00.01.25bi:

12/05/2022

This version of the policy will become effective 12/05/2022

Policy number 00.01.25bi is being issued to introduce a radiology network rule exception to Orthopedic Sports Medicine specialty when performed in the office setting, as identified in this policy.


Orthopedic Sports Medicine provider type has been added to the following codes in Attachment C2: 72020, 72040, 72050, 72052, 72070, 72072, 72074, 72080, 72081, 72082, 72083, 72084, 72100, 72110, 72114, 72120, 72170, 72190 ,72200, 72202, 72220, 73000, 73010, 73020, 73030, 73050, 73060, 73070, 73080, 73090, 73092, 73100, 73110, 73120, 73130, 73140, 73501, 73502, 73503, 73521, 73522, 73523, 73551, 73552, 73560, 73562, 73564, 73565, 73590, 73592, 77071 73600, 73610, 73620, 73630, 73650, and 73660​


Revisions From 00.01.25bh:

10/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 10/1/2022. 

The following CPT & HCPCS codes have been deleted from this policy:  
0012U 

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

A4596, E0183, 0332U, 0333U, 0334U, 0335U, 0336U, 0337U, 0338U, 0339U, 0340U, 0341U, 0342U, 0343U, 0344U, 0345U, 0346U, 0347U, 0348U, 0349U, 0350U, 0351U, 0352U, 0353U, 0354U

The following CPT/HCPCS code narratives have been revised in this policy: 
0276U and E0483 


Revisions From 00.01.25bg:

04/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 04/1/2022. 

The following CPT & HCPCS codes have been deleted from this policy: 
0097U and 0151U

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

0306U, 0307U, 0308U, 0309U, 0310U, 0311U, 0312U, 0313U, 0314U, 0315U, 0316U, 0317U, 0318U, 0319U, 0320U, 0321U and 0322U​​​

​​

Revisions From 00.01.25bf:

01/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 01/1/2022. 

The following CPT & HCPCS codes have been deleted from this policy: 0423T, 76101,
76102, 80500, 80502, and A4397

The following CPT & HCPCS codes have been added to this policy: 0285U, 0286U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0295U, 0296U, 0297U, 0298U, 0299U, 0300U, 0301U, 0302U, 0303U, 0304U, 0305U, 0689T, 0690T, 0691T, 0694T, 0697T, 0698T, 0701T, 77089, 77090, 77091, 77092, 80220, 80503, 80504, 80505, 80506, 81349, 81523, 81560, 8265


Revisions From 00.01.25be:

10/01/2021

This policy has been identified for the 10/1/2021 Quarterly Code Update. This version of the policy will become effective 10/01/2021. ​

The following CPT codes have been deleted from this policy: 0139U, 0168U

The following CPT & HCPCS codes have been added to this policy: A4453, K1021, K1023, K1024, K1025, K1026, K1027, 0018M, 0255U, 0256U, 0257U, 0258U, 0259U, 0260U, 0261U, 0262U, 0263U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0275U, 0276U, 0277U, 0278U, 0279U, 0280U, 0281U, 0282U, 0283U, 0284U

The following HCPCS code narrative has been revised in this policy: K1013


Revisions From 00.01.25bd:

07/01/2021

This version of the policy will become effective 07/01/2021.

Policy number 00.01.25bd is being issued to introduce a radiology network rule exception to allow reimbursement consideration by the Company for doppler studies when performed in the office setting by Vascular & Interventional Radiology specialty providers, as identified in this policy.

Vascular & Interventional Radiology provider type has been added to the following codes in Attachment C2: 93970, 93971

In addition, this policy has been impacted by the 07/01/2021 Quarterly Code Update​.
The following codes have been added to Attachment B2: 0248U, 0249U, 0250U, 0251U, 0252U, 0253U, 0254U, G0327

The following codes have been added to Attachment C1: 0648T, 0649T

 

Revisions From 00.01.25bc:

04/02/2021

This version of the policy will become effective 04/02/2021. 

In addition to codes previously included in Policy Update version bb as part of the 4/1/2021 Quarterly Code Update​, later released HCPCS codes have also been identified for this Code Update. 

The following HCPCS codes have been added to Attachment A2: K1013, K1020.


Revisions From 00.01.25bb:

04/01/2021

This version of the policy will become effective 04/01/2021. 

Policy number 00.01.25bb is being issued to introduce a radiology network rule exception to allow reimbursement for cardiac PET scan procedures done in the office setting when performed by cardiology specialty providers identified in this policy.

The following CPT codes have been added to Attachment C2: 78429, 78430, 78431, 78432, 78433, 78434, 78459, 78491, 78492

In addition, this policy has been identified for the 04/01/2021 Quarterly Code Update.

The following CPT codes have been added to Attachment B2: 0242U, 0243U, 0244U, 0245U, 0246U, 0247U

The following CPT codes have been deleted from Attachment B2: 0098U, 0099U, 0100U


Revisions From 00.01.25ba:

01/01/2021

This policy has been identified for the Annual Code Update. This version of the policy will become effective 01/01/2021. ​

The following CPT codes have been deleted from this policy: 0085T, 0111T, 76970, 78135, 81545

The following CPT & HCPCS codes have been added to this policy: 80143, 80151, 80161, 80167, 80179, 80181, 80189, 80193, 80204, 80210, 81168, 81191, 81192, 81193, 81194, 81278, 81279, 81338, 81339, 81347, 81348, 81351, 81352, 81353, 81357, 81360, 81419, 81513, 81514, 81529, 81546, 81554, 82077, 82681, U0005, 0017M, 0225U, 0226U, 0227U, 0228U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 76145

The following CPT & HCPCS code narratives have been revised in this policy: 70250, 71250, 71260, 71270, 74400, 74410, 74415, 74420, 74425, 76510, 76511, 76512, 76513, 78130, 80414, 80415, 82075, 0152U


Revisions From 00.01.25az:

10/01/2020

This policy has been identified for the Quarterly Code Update. This version of the policy will become effective 10/01/2020. Due to the COVID-19 Public Health Emergency, certain procedure codes have been released off-cycle and have varying effective dates. 

The following CPT & HCPCS codes have been added to this policy: 0015M, 0016M, 0203U, 0204U, 0205U, 0206U, 0207U, 0208U, 0209U, 0210U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0219U, 0220U, 0221U, 0222U, 0240U, 0241U, 86413, 87636, 87637, 87811, 87428, K1006, K1009, K1010, K1011, K1012​


Revisions From 00.01.25ay:

07/01/2020

This policy has been identified for the Quarterly Code Update. This version of the policy will become effective 07/01/2020.

The following CPT codes have been deleted from this policy: 0124U, 0125U, 0126U, 0127U, 0128U.

The following CPT codes have been added to this policy: 0172U, 0173U, 0174U, 0175U, 0176U, 0177U, 0178U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0202U, 0223U, 0224U, 87426, 77063

The following CPT codes have been revised in this policy: 0165U


Revisions From 00.01.25ax:

05/18/2020

This version of the policy will become effective 05/18/2020.

This policy is being updated to remove dermatology office place of service exceptions for certain laboratory services.

The following CPT codes have been deleted from Att B3: 88302, 88304, 88305, 88312, 88313, 88321, 88341, 88342


Revisions From 00.01.25aw:

04/01/2020

This policy has been identified for the 04/01/2020 Quarterly Code Update. This version of the policy will become effective 04/01/2020.

The following CPT/HCPCS codes have been added to this policy: 0014M, 0163U, 0164U, 0165U, 0166U, 0167U, 0168U, 0169U, 0170U, 0171U, G2023, G2024, U0001, U0002, U0003, U0004, 86328, 86769, 87635

The following CPT codes have been revised in this policy: 0154U, 0155U


Revisions From 00.01.25av:

01/01/2020

This policy has been identified for the 1/1/2020 Annual Code Update. This version of the policy will become effective 01/01/2020.

The following CPT/HCPCS codes have been deleted from this policy: 0081U, 0085U, 0482T, 74241, 74245, 74247, 74249, 74260, 78205, 78206, 78320, 78607, 78647, 78710, 78805, 78806, 78807, G0365, 97127, G0515

The following CPT/HCPCS codes have been added to this policy: 0564T, 80145, 80187, 80230, 80235, 80280, 80285, 81277, 81307, 81308, 81309, 81522, 81542, 81552, 87563, 0139U, 0140U, 0141U, 0142U, 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U, 0151U, 0152U, 0153U, 0154U, 0155U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 80305, 80306, 78429, 78430, 78431, 78432, 78433, 78434, 74221, 74248, 93985, 93986, 97129, 97130, L8033, A4226, E0787, E2398, K1001, K1002, K1003, K1004, K1005

The following CPT/HCPCS code narratives have been revised in this policy: 81350, 74022, 74210, 74220, 74230, 74240, 74246, 74250, 74251, 74270, 74280, 78459, 78491, 78492, 78800, 78801, 78802, 78803, 78804, L8032, B4185

The following ICD 10 codes have been added to this policy: H53.411, H53.412, H53.413, H53.419, H53.429, H54.10, H54.40, H54.50, H54.60


Revisions From 00.01.25au:

10/01/2019

This 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


Revisions From 00.01.25at:

08/19/2019

This version of the policy will become effective 08/19/2019.

This policy was expanded to allow certain place of service and provider exceptions for influenza testing services.

The following CPT codes have been deleted from Att B2 and added to Att B1: 87501, 87502, 87503.

 

In addition, this policy was expanded to allow the same exceptions for an add on code that may only be reported in conjunction with two primary radiation therapy codes that have specialist exceptions in place

 

The following CPT code has been added to Att C2: 77293


Revisions From 00.01.25as:

07/01/2019

This 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. 0558T


Revisions From 00.01.25ar:

01/01/2019

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

The following CPT & HCPCS codes have been deleted from this policy: 0346T, 77058, 77059, 78270, 78271, 78272, 81211, 81213, 81214, K0903

The following CPT & HCPCS codes have been added to this policy: E0447, E0467, A6460, A6461, L8698, 0541T, 0542T, 76978, 76979, 76981, 76982, 76983, 77046, 77047, 77048, 77049, 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 & HCPCS codes have been revised in this policy: 77387, 81162, 81212, 81215, 81216, 81217, 81244, 81287, 81327, E0218, E0483


Revisions From 00.01.25aq:

04/01/2018

Revised policy number 00.01.25aq was issued effective 04/01/2018.

The below limited circumstances have been removed from Attachment B3, effective 04/01/2018, and are no longer eligible for reimbursement when performed by participating physician specialty office-based pathologists or free-standing office pathology practices:

Service codes 88187, 88188, 88189, 88291, 88302 modifier 26, 88304 modifier 26, 88305, 88312 modifier 26, 88313 modifier 26, 88341 modifier 26 and 88342 modifier 26 when performed by a Pathologist, Anatomic pathologists, or Anatomic and Clinical pathologists in place of service office.

    • 88313, 88341, 88342, 88313 modifier 26, 88341 modifier 26, 88342 modifier 26, 88304 modifier 26, 88305 modifier 26, and 88312 modifier 26 when performed by a Oral and Maxillofacial Pathology in place of service office.

    New code K0903 For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each

 

Revisions From 00.01.25ap:

01/01/2018

This policy becomes effective 01/01/2018.

The following HCPCS codes have been added to Attachment A1 of this policy:

E0953, E0954, L3761, L8625, L8694, L7700


The following HCPCS code narratives have been revised to Attachment A2 of this policy:

L3760, L8618, L8624, L8691

The following CPT codes have been added to Attachment B2 of this policy:

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 CPT codes have been deleted from Attachment B2 of this policy:

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

The following CPT code narratives have been revised to Attachment B2 of this policy:

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

The following CPT codes have been added to Attachment C1 of this policy:

0482T, 0501T, 0502T, 0503T, 0504T, 71045, 71046, 71047, 71048, 74018, 74019, 74021

The following CPT codes have been deleted from Attachment C1 of this policy:

71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 74000, 74010, 74020, 77422, 78190, G0202, G0204, G0206

The following CPT code narratives have been revised to Attachment C1 of this policy:

76000, 76881, 76882

The following CPT codes have been deleted from Attachment C2:

G0202, G0204, G0206

The following CPT codes have been added to Attachment D of this policy:

97127, G0515, 97763

The following CPT codes have been deleted from Attachment D of this policy:

97532, 97762

The following CPT code narratives have been revised to Attachment D of this policy:

97760, 97761


Revisions From 00.01.25ao:

12/01/2017

This policy becomes effective 12/01/2017.

This policy has been expanded to include Physician Assistants (PAs) to be eligible to perform services in a specialty group.


10/1/2025
10/6/2025
00.01.25
Claim Payment Policy Bulletin
Commercial
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.