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

STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point-of-Service (POS) Products

Notification Issue Date:

This policy has been identified for the CPT annual code update, effective 01/02/2015.

The following CPT codes have been revised on this policy:

86900: Blood typing, serologic; ABO

86901: Blood typing, serologic; Rh (D)

Title:

STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point-of-Service (POS) Products

Policy #:

MA00.021b

Policy

For Health Maintenance Organization (HMO) and Point-of-Service (POS) products, STAT laboratory (lab) tests performed in an outpatient hospital setting are covered and eligible for reimbursement consideration by the Company when they are performed to obtain immediate results to assist in determining an individual's course of treatment. For a list of eligible STAT lab tests, refer to Attachment A.

Precertification and referrals are not required for the STAT lab tests listed in Attachment A. These tests may be performed by any participating hospital laboratory, provided that a participating provider (ie, the individual's primary care physician [PCP] or specialist) requests the STAT lab test via a written order.

Lab tests that are not included in Attachment A require precertification if they are to be performed on a STAT basis. When ordered in conjunction with STAT lab tests, routine lab tests require precertification in order to be eligible for additional reimbursement consideration.

Guidelines

Participating primary care physicians (PCP) and specialists may direct any STAT laboratory (lab) test to any participating hospital with a written physician order.

Routine lab tests and those not listed in Attachment A must be directed to the PCP-designated laboratory site for Health Maintenance Organization (HMO) and Point-of-Service (POS) products.

In geographic areas with a capitated lab program, STAT lab tests listed in Attachment A and performed in an outpatient hospital setting that is the member's designated cap site are included in the capitation payment and are, therefore, not eligible for separate reimbursement.

Description

Laboratory (lab) testing is an important component of clinical treatment and is performed to provide information for the diagnosis, prevention, or treatment of disease, or the assessment of an individual’s health.

At times, it may be necessary for providers to perform specific laboratory tests to obtain immediate results to assist in determining the individual's course of treatment. These tests are defined as STAT lab tests and are performed in the outpatient hospital setting.

References

Evidence of Coverage.

Provider Manual.

Coding

CPT Procedure Code Number(s)

Refer to Attachment A for a listing of STAT laboratory tests.

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA00.021b:

10/16/2024	This policy has been reissued in accordance with the Company's annual review process.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
01/01/2021	This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021. The following CPT code narrative has been revised in Attachment A of this policy: 82670

Revisions From MA00.021a:

02/09/2015

This policy has been identified for the CPT annual code update, effective 01/02/2015.

The following CPT codes have been revised on this policy:

86900: Blood typing, serologic; ABO

86901: Blood typing, serologic; Rh (D)

Revisions From MA00.021:

01/01/2015

This is a new policy.

Version Effective Date:

1/1/2021

Version Issued Date:

1/4/2021

Version Reissued Date:

10/16/2024