Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

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

Notification Issued Date: N/A

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

Policy Attachment

Attachment to Policy #

MA00.010as

Attachment:

Policy #:

MA00.010as

Description:

Laboratory Network Rules and Limited Circumstances

Title:

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

LABORATORY NETWORK RULE AND LIMITED CIRCUMSTANCES

NETWORK RULES PROCEDURE CODE LIST

The CPT/HCPCS codes listed below are eligible to all professional specialties in place of service office, independent lab, and outpatient hospital:

Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
80220		1/01/2022
80305		1/1/2020
80306		1/1/2020
81000		1/1/1984
81001		1/1/1996
81002		1/1/1984
81003		1/1/1993
81005		1/1/1984
81015		1/1/1984
81025		1/1/1993
81349		1/01/2022
81523		1/01/2022
81560		1/01/2022
82270		1/1/1985
82271		1/1/2006
82272		1/1/2006
82273		1/1/1982	12/31/2005
82274		1/1/2002
82653		1/01/2022
82947		1/1/1984
82948		1/1/1984
82950		1/1/1984
82951		1/1/1984
82952		1/1/1984
82962		1/1/1993
82985		1/1/1984
83009		1/1/2005
83013		1/1/1999
83014		1/1/1999
83026		1/1/1993
83036		1/1/1985
83037		1/1/2006
83516		1/1/1995
83518		1/1/1993
83521		1/01/2022
83529		1/01/2022
83986		1/1/1984
85002		1/1/1984
85007		1/1/1984
85009		1/1/1984
85013		1/1/1993
85018		1/1/1984
85610		1/1/1984
85651		1/1/1984
85660		1/1/1984
86015		1/01/2022
86036		1/01/2022
86037		1/01/2022
86051		1/01/2022
86052		1/01/2022
86053		1/01/2022
86231		1/01/2022
86258		1/01/2022
86294		1/1/2001
86308		1/1/1993
86317		1/1/1988
86318		1/1/1989
86362		1/01/2022
86363		1/01/2022
86364		1/01/2022
86381		1/01/2022
86386		1/1/2012
86403		1/1/1986
86406		1/1/1995
86430		1/1/1984
86596		1/01/2022
86677		1/1/1993
86701		1/1/1993
86710		1/1/1993
87081		1/1/1984
87084		1/1/1982
87086		1/1/1984
87154		1/01/2022
87172		1/1/2001
87205		1/1/1985
87210		1/1/1985
87275		1/1/2001
87276		1/1/1998
87338		1/1/2000
87400		1/1/2001
87501		08/19/2019
87502		08/19/2019
87503		08/19/2019
87634		04/24/2023
87651		04/24/2023
87802		1/1/2002
87804		1/1/2002
87807		04/24/2023
87808		6/1/2017
87810		1/1/1998
87880		1/1/1998
89190		1/1/1985
89321		1/1/2001
G0027		1/1/1995
G0107		1/1/1998	12/31/2006
G0435		4/1/2010
Q0111		1/1/1994
Q0112		1/1/1994
Q0113		1/1/1994

Version Effective Date:

01/01/2025

Version Issued Date:

01/31/2025

Version Reissued Date:

N/A