Commercial

Medical Policy

Notification

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

Notification Issue Date:

This version of the policy will become effective 07/31/2023.

Policy number 00.03.07ak is being issued to communicate the removal of provider specialty exceptions in the office setting for certain laboratory services identified in attachment B1 of this policy.

Allergy and Immunology Specialty:

89190

Cardiology and Interventional Cardiology Specialty:

83880

Hematology Oncology and Medical Oncology Specialty:

85007, 85008, 85009, 85013, 85014, 85027, 85032, 85044, 85048

Nephrology Specialty:

81015, 81007

Orthopedic Surgery Specialty:

89050, 89051, 89060

Reproductive Endocrinology Specialty:

G0027

Rheumatology and Pediatric Rheumatology Specialty:

83872, 85810, 89050, 89051, 89055

Urology Specialty:

G0027, 81015, 81020, 87205, 81007

---------------------

Note: On May 25, 2023 the wording of this Notification message was updated for clarity to include the Provider Specialty headings with the clinical codes.

Title:

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

Policy #:

00.03.07au

Policy

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

CPT Procedure Code Number(s)

See Attachments.

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

See Attachments.

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 00.03.07au:

10/01/2026

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2026.

The following CPT code has been added to Attachment A1 of the policy:

0660U, 0661U, 0662U, 0663U, 0664U, 0665U, 0666U, 0667U, 0668U, 0669U, 0670U, 0671U, 0672U, 0673U, 0674U, 0675U, 0676U, 0677U, 0678U, 0679U, 0680U, 0681U, 0682U, 0683U, 0684U, 0685U, 0686U, 0687U, 0688U, 0689U, 0690U, 0691U, 0692U, 0693U, 0694U, 0695U, 0696U, 0697U, 0698U

The following CPT code in Attachment A1 of the policy have been terminated:

0585U

The following CPT codes in Attachment A1 of the policy have undergone a code narrative revision:

0247U, 0575U, 0591U

Revisions From 00.03.07at:

07/01/2026

This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2026.

The following CPT code has been added to Attachment A1 of the policy:

87638

The following CPT codes in Attachment A1 of the policy have been terminated:

0029U, 0032U, 0423U, 0577U

The following CPT codes in Attachment A1 of the policy have undergone a code narrative revision:

0034U, 0598U

Revisions From 00.03.07as:

04/01/2026

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2026.

The following CPT codes have been added to Attachment A1 of the policy:
0614U, 0615U, 0616U, 0617U, 0618U, 0619U, 0620U, 0621U, 0622U, 0623U, 0624U, 0625U, 0626U, 0627U, 0628U, 0629U, 0630U.

The following CPT codes in Attachment A1 of the policy have undergone a code narrative revision:
0256U, 0580U.

Revisions From 00.03.07ar:

01/01/2026

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2026.

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

87182, 87183, 87494, 87627, 0600U, 0601U, 0602U, 0603U, 0604U, 0605U, 0606U, 0607U, 0608U, 0609U, 0610U, 0611U, 0612U, and 0613U

The following CPT/HCPCS codes on Attachment A1 of this policy have termed:

0033U, 0131U, 0132U, 0135U, 0361U, 0544U, 0550U, and 0551U

Procedure code 87812 has been added to Attachment B2.

Revisions From 00.03.07aq:

10/01/2025

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

The following CPT codes have been been added to Attahment A1 of this policy:

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

Revisions From 00.03.07ap:

04/01/2025

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

The following CPT codes have been added to attachment A1 of this policy:

0531U, 0532U, 0533U, 0534U, 0535U, 0536U, 0537U, 0538U, 0539U, 0540U, 0541U, 0542U, 0543U, 0544U, 0545U, 0546U, 0547U, 0548U, 0549U, 0550U, and 0551U

Revisions From 00.03.07ao:

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 termed and removed from this policy:

81433, 81436, 81438, 86327, 86490, 88388, 0346U, 0352U, 0380U,0428U, 0448U, 0500T

The following CPT codes have been added to this policy:

81515, 87626, 81195, 81558, 82233, 82234, 83884, 84393, 84394, 86581, 87513, 87564, 87594, 0523U, 0524U, 0525U, 0526U, 0528U, 0529U, 0530U

The following CPT code narratives have been revised in this policy:
81432, 81435, 81437, 87624, 88387, 0095U,0365U

Revisions From 00.03.07an:

04/01/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2024.

The following CPT codes have been termed and removed from this policy:

0354U and 0416U

The following CPT codes have been added to this policy:

0439U, 0440U, 0441U, 0442U, 0443U, 0444U, 0445U, 0446U, 0447U, 0448U and 0449U

Revisions From 00.03.07am:

01/01/2024

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

The following CPT code has been termed and removed from this policy:

0014M

The following CPT 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, 87523, 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

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

81171, 81172, 81243, 81244, 81445, 81449, 81450, 81451, 81455, 81456, 0351U, 0356U

Revisions From 00.03.07al:

10/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2023

The following CPT codes have been termed and removed from this policy:

0357U and 0386U

The following CPT codes have been added to this policy:

0403U, 0404U, 0405U, 0406U, 0407U, 0409U, 0410U, 0411U, 0412U, 0413U, 0414U, 0416U, 0417U, 0418U, 0419U

The following CPT code narratives have been revised in this policy:
0269U, 0271U, 0272U, 0274U, 0277U, 0278U, 0362U

Revisions From 00.03.07ak:

07/31/2023

89190, 83880, 85007, 85008, 85009, 85013, 85014, 85027, 85032, 85044, 85048, 81015, 81007, 89050, 89051, 89060, G0027, 83872, 85810, 89050, 89051, 89055, G0027, 81015, 81020, 87205 and 81007

Revisions From 00.03.07aj:

04/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2023.

The following CPT codes have been termed and removed from this policy:

G2023 and G2024

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 and 0095U

Revisions From 00.03.07ai:

01/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2023

The following CPT codes have been added to this policy:

81418, 81449, 81451, 81456, 84433, 87467, 87468, 87469, 87478, 87484, 0355U, 0356U, 0358U, 0359U, 0360U, 0361U, 0362U, 0363U, 0751T, 0752T, 0753T, 0754T, 0755T, 0756T, 0757T, 0758T, 0759T, 0760T, 0761T, 0762T and 0763T.

The following CPT code narratives have been revised in this policy:
81445, 81450 and 81455

Revisions From 00.03.07ah:

10/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2022.

The following CPT code has been deleted from this policy:

0012U

The following CPT codes have been added to this policy:

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

The following CPT code narrative has been revised in this policy:

0276U

Revisions From 00.03.07ag:

04/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2022.

The following CPT codes have been deleted from this policy:

0097U and 0151U

The following CPT 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

The following CPT code narrative has been revised in this policy:

0022U

Revisions From 00.03.07af:

01/02/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 01/02/2022.

The following CPT codes have been deleted from this policy:

0423T, 80500, and 80502

The following CPT 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, 80220, 80503, 80504, 80505, 80506, 81349, 81523, 81560, 82653, 83521, 83529, 86015, 86036, 86037, 86051, 86052, 86053, 86231, 86258, 86362, 86363, 86364, 86381, 86596, and 87154

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

81228, 81229, 82656, 87426, and 87449

Revisions From 00.03.07ae:

01/01/2022

This version of the policy will become effective 01/01/2022.

Policy number 00.03.07ae is being issued to introduce a HMO or HMO-POS member's designated laboratory capitation exception to allow fee-for-service reimbursement consideration by the Company for certain Assisted Reproductive Technology (ART) services, as identified in this policy, when performed in the office setting by Reproductive Endocrinology specialty providers.

The following CPT codes have been added to the applicable table in Attachment B1: 89260, 89261, 89264, 89268, 89272, 89280, 89281, 89352, 89353, 89354, 89356

In addition, this policy has been impacted by the 01/01/2022 Annual Code Update.

The following CPT codes have been added to Attachment A1:

placeholder for new 1/1 codes to be added.

Revisions From 00.03.07ad:

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: 0018M, 0248U, 0249U, 0250U, 0251U, 0252U, 0253U, 0254U, 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, G0327

Revisions From 00.03.07ac:

04/01/2021

This policy has been identified for the 04/01/2021 Quarterly Code Update. This version of the policy will become effective 04/01/2021.

The following CPT codes have been added to Attachment A1: 0242U, 0243U, 0244U, 0245U, 0246U, 0247U.

The following CPT codes have been deleted from Attachment A1: 0098U, 0099U, 0100U.

Revisions From 00.03.07ab:

01/01/2021

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

The following CPT code narratives have been revised in this policy: 80414, 80415, 82075, 82670, 0152U
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

The following
The following CPT code narratives have been revised in this policy: 80414, 80415, 82075, 82670, 0152U

Revisions From 00.03.07aa:

10/01/2020

This policy has been identified for the October 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.

Revisions From 00.03.07z:

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

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

Revisions From 00.03.07y:

04/01/2020

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

The following CPT codes have been deleted from this policy: 0081U, 0085U

The following CPT & HCPCS codes have been added to this policy: 0014M, 0163U, 0164U, 0165U, 0166U, 0167U, 0168U, 0169U, 0170U, 0171U, U0001, U0002, U0003, U0004, G2023, G2024, 0564T, 80145, 80187, 80230, 80235, 80280, 80285, 80305, 80306, 81277, 81307, 81308, 81309, 81522, 81542, 81552, 86328, 86769, 87563, 87653, 0139U, 0140U, 0141U, 0142U, 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U, 0151U, 0152U, 0153U, 0154U, 0155U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U

Revisions From 00.03.07x:

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 00.03.07w:

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

Revisions From 00.03.07v:

01/01/2019

This 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

Revisions From 00.03.07u:

01/01/2018

This 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

Revisions From 00.03.07t:

12/01/2017

This 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.

Revisions From 00.03.07s:

10/01/2017

This 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

Revisions From 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

Revisions From 00.03.07q:

08/01/2017

Revised 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.

Revisions From 00.03.07p:

02/01/2017

This 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

Revisions From 00.03.07o:

01/01/2017

This 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

Revisions From 00.03.07n:

01/01/2016

This 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

Revisions From 00.03.07m:

01/01/2016

The 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.

Revisions From 00.03.07l:

07/01/2015

This policy has been identified for CPT code update, effective 07/01/2015.

The following CPT codes been added to this policy: 0009M, 0010M

Revisions From 00.03.07k:

03/01/2015

Policy 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.

Revisions From 00.03.07j:

01/01/2015

Policy # 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

Revisions From 00.03.07i:

12/10/2014

Claim 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

Revisions From 00.03.07h:

07/01/2014

Policy # 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

Revisions From 00.03.07g:

02/01/2014

Revised 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

Revisions From 00.03.07f:

07/31/2013

Claim 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

Revisions From 00.03.07e:

07/01/2013

Policy # 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

Revisions From 00.03.07d:

01/01/2013

This 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

Revisions From 00.03.07c:

09/15/2012

Policy # 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

Revisions From 00.03.07b:

04/01/2012

Policy # 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

Revisions From 00.03.07a:

01/01/2012

Policy # 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

Revisions From 00.03.07:

10/01/2011

This 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:

Version Issued Date:

10/1/2026

Version Reissued Date: