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 cont'd.

Title:

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

LABORATORY NETWORK RULES AND LIMITED CIRCUMSTANCES

LIMITED CIRCUMSTANCES PROCEDURE CODE LIST

The limited circumstances of laboratory services that a participating specialist, other than an independent or a physiological laboratory, may provide, and for which the provider may be eligible for reimbursement, are listed below:

All Professional Specialties (In All Places of Service)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
0202U		05/20/2020
0223U		06/25/2020
0224U		06/25/2020
0225U		08/10/2020
0226U		08/10/2020
0240U		10/6/2020
0241U		10/6/2020
86328		04/10/2020
86413		9/8/2020
87636		10/6/2020
87637		10/6/2020
86769		04/10/2020
87426		06/25/2020
87635		03/13/2020
87811		10/6/2020
87428		11/10/2020
G2023		03/01/2020	05/11/2023
G2024		03/01/2020	05/11/2023
U0001		02/04/2020
U0002		02/04/2020
U0003		04/14/2020	05/11/2023
U0004		04/14/2020	05/11/2023
U0005		01/01/2021	05/11/2023

ALL Professional Specialties (Office and Outpatient Place of Service)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
86580		01-01-1982
87899		01-01-1998

Cardiology and Interventional Cardiology (Office Place of Service Only)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
83880		12-10-2014

Dermatology (Office Place of Service Only)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
87220		01-01-2017
88302		01-01-1982	05-18-2020
88304		01-01-1985	05-18-2020
88305		01-01-1982	05-18-2020
88312		01-01-1982	05-18-2020
88313		01-01-1982	05-18-2020
88321		01-01-1982	05-18-2020
88331	59	07-31-2013
88341		01-01-2015	05-18-2020
88342		01-01-1985	05-18-2020

Hematology/Oncology, Medical Oncology, Pediatric Hematology and Oncology (Office and Outpatient Place of Service)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
G0306		01-01-2004
G0307		01-01-2004
85004		01-01-2003
85008		01-01-2017
85014		01-01-1984
85025		01-01-1987
85027		01-01-1985
85032		01-01-2003
85044		01-01-2017
85048		01-01-1984
85049		01-01-2003

Hematology/Oncology (Office and Outpatient Place of Service)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
88738		01-01-2010

Nephrology (Office and Outpatient Place of Service)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
81007		01-01-2017

Ophthalmology/Optometry (Office and Outpatient Place of Service)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
83861		01-01-2014

Oral and Maxillofacial Pathology (Office Place of Service Only)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
88313		01-01-1982	03-31-2018
88313	26	01-01-1982	03-31-2018
88341		01-01-2015	03-31-2018
88341	26	01-01-2015	03-31-2018
88342		01-01-1985	03-31-2018
88342	26	01-01-1985	03-31-2018
88304	26	01-01-1985	03-31-2018
88305	26	01-01-1985	03-31-2018
88312	26	01-01-1982	03-31-2018

Oral and Maxillofacial Pathology (Outpatient Place of Service only )
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
88304	26	01-01-1985
88305	26	01-01-1985
88307	26	01-01-1982
88311	26	01-01-1982
88312	26	01-01-1982
88313	26	01-01-1982
88313		01-01-1982
88341		01-01-2015
88341	26	01-01-2015
88342		01-01-1985
88342	26	01-01-1985
88346	26	01-01-1985
88365	26	01-01-1989

Orthopedic Surgeon (Outpatient Place of Service Only)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
83872		01-01-2017
89050		01-01-2017
89051		01-01-2017
89060		01-01-2017

Pathology, Anatomic Pathology and Anatomic and Clinical Pathology (Office Place of Service Only)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
88305		01-01-1982	03-31-2018

Pathology, Anatomic Pathology and Anatomic and Clinical Pathology (Office Place of Service Only)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
88187		07-01-2009	03-31-2018
88188		07-01-2009	03-31-2018
88189		07-01-2009	03-31-2018
88291		07-01-2009	03-31-2018
88302	26	01-01-1982	03-31-2018
88304	26	01-01-1985	03-31-2018
88305	26	01-01-1982	03-31-2018
88312	26	01-01-1982	03-31-2018
88313	26	01-01-1982	03-31-2018
88321	26	01-01-1982	03-31-2009
88341	26	01-01-2015	03-31-2018
88342	26	01-01-1985	03-31-2018

Pathology, Anatomic Pathology and Anatomic and Clinical Pathology (Outpatient Place of Service Only)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
88104	26	11-01-2009
88106	26	11-01-2009
88107	26	11-01-2009	12-31-2011
88108	26	11-01-2009
88112	26	11-01-2009
88125	26	11-01-2009
88130		11-01-2009
88140		11-01-2009
88155		11-01-2009
88160	26	11-01-2009
88161	26	11-01-2009
88162	26	11-01-2009
88172	26	11-01-2009
88173	26	11-01-2009
88182	26	11-01-2009
88187		07-01-2009
88188		07-01-2009
88189		07-01-2009
88230		11-01-2009
88233		11-01-2009
88235		11-01-2009
88237		11-01-2009
88239		11-01-2009
88240		11-01-2009
88241		11-01-2009
88245		11-01-2009
88248		11-01-2009
88249		11-01-2009
88261		11-01-2009
88262		11-01-2009
88263		11-01-2009
88264		11-01-2009
88267		11-01-2009
88269		11-01-2009
88271		11-01-2009
88272		11-01-2009
88273		11-01-2009
88274		11-01-2009
88275		11-01-2009
88280		11-01-2009
88283		11-01-2009
88285		11-01-2009
88289		11-01-2009
88291		07-01-2009
88300	26	11-01-2009
88302	26	01-01-1982
88304	26	01-01-1985
88305	26	01-01-1982
88307	26	11-01-2009
88309	26	11-01-2009
88311	26	11-01-2009
88312	26	01-01-1982
88313	26	01-01-1982
88314	26	11-01-2009
88318	26	11-01-2009	12-31-2011
88319	26	11-01-2009
88321	26	01-01-1982	03-31-2009
88323	26	11-01-2009
88331	26	11-01-2009
88332	26	11-01-2009
88333	26	11-01-2009
88334	26	11-01-2009
88341	26	01-01-2015
88342	26	01-01-1985
88346	26	11-01-2009
88347	26	11-01-2009	12-31-2015
88348	26	11-01-2009
88349	26	11-01-2009	12-31-2014
88356	26	11-01-2009
88358	26	11-01-2009
88360	26	11-01-2009
88361	26	11-01-2009
88362	26	11-01-2009
88365	26	11-01-2009
88367	26	11-01-2009
88368	26	11-01-2009

Rheumatology and Pediatric Rheumatology (Office and Outpatient Place of Service)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
G0306		01-01-2004
G0307		01-01-2004
Q0114		01-01-1994
83872		01-01-1984
85004		01-01-2003
85014		01-01-1984
85025		01-01-1987
85027		01-01-1985
85032		01-01-2003
85044		01-01-2017
85048		01-01-1984
85049		01-01-2003
85055		01-01-2004
85810		07-01-2009
88738		01-01-2010
89050		01-01-1984
89051		01-01-1984
89055		01-01-2017
89060		01-01-1986

Reproductive Endocrinology (Office Place of Service)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
89250		07-01-2011
89251		01-01-2016
89253		07-01-2011
89254		01-01-2016
89255		07-01-2011
89257		07-01-2011
89258		01-01-2016
89259		01-01-2016
89260		07-01-2011
89261		01-01-2016
89264		01-01-2016
89268		01-01-2016
89272		01-01-2016
89280		07-01-2011
89281		01-01-2016
89290		01-01-2016
89291		01-01-2016

Reproductive Endocrinology (Office and Outpatient Place of Service)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
82670		01-01-1984
82671		01-01-2017
82672		01-01-2017
82681		01-01-2021
83001		01-01-1984
83002		01-01-1984
84144		01-01-1984
84702		01-01-1987
84703		01-01-1987
84704		01-01-2017
84830		01-01-2017
89300		01-01-1984
89310		01-01-1984
89320		01-01-1984
89321		01-01-2016
89322		01-01-2016
89325		01-01-2016
89329		01-01-2016
89330		01-01-2016
89331		01-01-2016
89335		01-01-2017
89337		01-01-2017
89352		01-01-2017
89353		01-01-2017
89354		01-01-2017
89356		01-01-2017
89398		01-01-2016

Urology (Office and Outpatient Place of Service)
Procedure Code	Modifier	Date Code Added to the Policy	Date Code Removed from the Policy
81007		01-01-2017
81020		01-01-2017
89300		01-01-2017
89310		01-01-1984
89320		01-01-1984
89321		01-01-2016
89322		01-01-2016

Version Effective Date:

01/01/2025

Version Issued Date:

01/31/2025

Version Reissued Date:

N/A