Notification

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


Notification Issue Date: 02/14/2020



Policy Attachment



Attachment to Policy # 00.01.25ax


Attachment:B1

Policy #:00.01.25ax

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


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

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



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
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
82270
1/1/1985
82271
1/1/2006
82272
1/1/2006
82273
1/1/1982
12/31/2005
82274
1/1/2002
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
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
86294
1/1/2001
86308
1/1/1993
86317
1/1/1988
86318
1/1/1989
86386
1/1/2012
86403
1/1/1986
86406
1/1/1995
86430
1/1/1984
86677
1/1/1993
86701
1/1/1993
86710
1/1/1993
87081
1/1/1984
87084
1/1/1982
87086
1/1/1984
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
87802
1/1/2002
87804
1/1/2002
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: 05/18/2020
Version Issued Date: 05/18/2020
Version Reissued Date: N/A



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