Notification



Notification Issue Date:



Policy Attachment



Attachment to Policy # 00.03.07y


Attachment:A2

Policy #:00.03.07y

Description:HCPCS CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE

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


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.


HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODES INCLUDED IN CAPITATION TO THE PRIMARY CARE PHYSICIAN'S (PCP'S) DESIGNATED LABORATORY SITE

NOTES:
  • The Effective Date indicates either the effective date of the code and/or the date the code became included in capitation to the outpatient laboratory.
  • The Delete Date indicates either the date the code becomes invalid and/or the date the code is no longer considered capitated to the outpatient laboratory.
HCPCS CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE
HCPCS Code
Code Narrative
Effective Date
Delete Date
G0027
Semen analysis; presence and/or motility of sperm excluding huhner
10/01/2011
G0103
Prostate cancer screening; prostate specific antigen test (psa)
10/01/2011
G0123
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision
10/01/2011
G0124
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician
10/01/2011
G0141
Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
10/01/2011
G0143
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision
10/01/2011
G0144
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision
10/01/2011
G0145
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision
10/01/2011
G0147
Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision
10/01/2011
G0148
Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening
10/01/2011
G0306
Complete cbc, automated (hgb, hct, rbc, wbc, without platelet count) and automated wbc differential count
10/01/2011
G0307
Complete cbc, automated (hgb, hct, rbc, wbc; without platelet count)
10/01/2011
G0328
Colorectalcancer screening; fecal-occult blood test, immunoassay, 1-3 simultaneous determinations.
10/01/2011
G0416
Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method
10/01/2011
G0417
Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 21-40 specimens
10/01/2011
12/31/2014
G0418
Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 41-60 specimens
10/01/2011
12/31/2014
G0419
Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, greater than 60 specimens
10/01/2011
12/31/2014
G0431
Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class
10/01/2011
12/31/2015
G0432
Infectious agent antigen detection by enzyme immunoassay (eia) technique, qualitative or semi-quantitative, multiple-step method, hiv-1 or hiv-2, screening
10/01/2011
G0433
Infectious agent antigen detection by enzyme-linked immunosorbent assay (elisa) technique, antibody, hiv-1 or hiv-2, screening
10/01/2011
G0434
Drug screen, other than chromatographic; any number of drug classes, by clia waived test or moderate complexity test, per patient encounter
10/01/2011
12/31/2015
G0435
Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, hiv-1 or hiv-2, screening
10/01/2011
G0452
Molecular pathology procedure; physician interpretation and report
01/01/2013
G0455
Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen
01/01/2013
G0461
Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain
01/01/2014
12/31/2014
G0462
Immunohistochemistry or immunocytochemistry, per specimen; each additional single or multiplex antibody stain (list separately in addition to code for primary procedure)
01/01/2014
12/31/2014
G0464
Colorectal cancer screening; stool-based dna and fecal occult hemoglobin (e.g., kras, ndrg4 and bmp3) 01/01/2015
G0475
HIV antigen/antibody, combination assay, screening 01/01/2016
G0476
Infectious agent detection by nucleic acid (dna or rna); human papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to PAP test 01/01/2016
G0477
Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg, immunoassay) capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service. 01/01/2016
G0478
Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg, immunoassay) read by instrument-assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service. 01/01/2016
G0479
Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers (eg, immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service. 01/01/2016
G0480
Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed. 01/01/2016
G0481
Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed. 01/01/2016
G0482
Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed. 01/01/2016
G0483
Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed. 01/01/2016
G0659
Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes









01/01/2017
G2023
Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source
03/01/2020
G2024
Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source
03/01/2020
G6030
Amitriptyline 01/01/2015
G6031
Benzodiazepines 01/01/2015
G6032
Desipramine 01/01/2015
G6034
Doxepin 01/01/2015
G6035
Gold 01/01/2015
G6036
Assay of imipramine 01/01/2015
G6037
Nortriptyline 01/01/2015
G6038
Salicylate 01/01/2015
G6039
Acetaminophen 01/01/2015
G6040
Alcohol (ethanol); any specimen except breath 01/01/2015
G6041
Alkaloids, urine, quantitative 01/01/2015
G6042
Amphetamine or methamphetamine 01/01/2015
G6043
Barbiturates, not elsewhere specified 01/01/2015
G6044
Cocaine or metabolite 01/01/2015
G6045
Dihydrocodeinone 01/01/2015
G6046
Dihydromorphinone 01/01/2015
G6047
Dihydrotestosterone 01/01/2015
G6048
Dimethadione 01/01/2015
G6049
Epiandrosterone 01/01/2015
G6050
Ethchlorvynol 01/01/2015
G6051
Flurazepam 01/01/2015
G6052
Meprobamate 01/01/2015
G6053
Methadone 01/01/2015
G6054
Methsuximide 01/01/2015
G6055
Nicotine 01/01/2015
G6056
Opiate(s), drug and metabolites, each procedure 01/01/2015
G6057
Phenothiazine 01/01/2015
G6058
Drug confirmation, each procedure 01/01/2015
G9143
Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s)
10/01/2011
P2028
Cephalin flocculation, blood
10/01/2011
P2029
Congo red, blood
10/01/2011
P2031
Hair analysis (excluding arsenic)
10/01/2011
P2033
Thymol turbidity, blood
10/01/2011
P2038
Mucoprotein, blood (seromucoid) (medical necessity procedure)
10/01/2011
P3000
Screening papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision
10/01/2011
P3001
Screening papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician
10/01/2011
P7001
Culture, bacterial, urine; quantitative, sensitivity study
10/01/2011
Q0111
Wet mounts, including preparations of vaginal, cervical or skin specimens
10/01/2011
Q0112
All potassium hydroxide (koh) preparations
10/01/2011
Q0113
Pinworm examination
10/01/2011
Q0114
Fern test
10/01/2011
Q0115
Post-coital direct, qualitative examinations of vaginal or cervical mucous
10/01/2011
S3600
Stat laboratory request (situations other than s3601)
10/01/2011
S3620
Newborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel (e.g., galactose; hemoglobin, electrophoresis; hydroxyprogesterone, 17-d; phenylanine (pku); and thyroxine, total)
10/01/2011
S3625
Maternal serum triple marker screen including alpha-fetoprotein (apf), estriol, and human chorionic gonadotropin (hcg)
10/01/2011
S3626
Maternal serum quadruple marker screen including alpha-fetoprotein (afp), estriol, human chorionic gonadotropin (hcg), and inhibin a
10/01/2011
S3630
Eosinophil count, blood, direct
10/01/2011
S3645
Hiv-1 antibody testing of oral mucosal transudate
10/01/2011
S3650
Saliva test, hormone level; during menopause
10/01/2011
S3652
Saliva test, hormone level; to assess preterm labor risk
10/01/2011
S3655
Antisperm antibodies test (immunobead)
10/01/2011
S3708
Gastrointestinal fat absorption study
10/01/2011
S3711
Circulating tumor cell test
10/01/2011
03/31/2012
S3713
Kras mutation analysis testing
10/01/2011
03/31/2012
S3721
Prostate cancer antigen 3 (PCA3) testing
04/01/2012
12/31/2015
S3722
Dose optimization by area under the curve (auc) analysis, for infusional 5-fluorouracil
01/01/2012
S3800
Genetic testing for amyotrophic lateral sclerosis (als)
10/01/2011
S3818
Complete gene sequence analysis; brca 1 gene
10/01/2011
03/31/2012
S3819
Complete gene sequence analysis; brca 2 gene
10/01/2011
03/31/2012
S3820
Complete brca1 and brca2 gene sequence analysis for susceptibility to breast and ovarian cancer
10/01/2011
03/31/2012
S3822
Single mutation analysis (in individual with a known brca1 or brca2 mutation in the family) for susceptibility to breast and ovarian cancer
10/01/2011
03/31/2012
S3823
Three-mutation brca1 and brca2 analysis for susceptibility to breast and ovarian cancer in ashkenazi individuals
10/01/2011
03/31/2012
S3828
Complete gene sequence analysis; mlh1 gene
10/01/2011
03/31/2012
S3829
Complete gene sequence analysis; mlh2 gene
10/01/2011
03/31/2012
S3830
Complete mlh1 and mlh2 gene sequence analysis for hereditary nonpolyposis colorectal cancer (hnpcc) genetic testing
10/01/2011
03/31/2012
S3831
Single-mutation analysis (in individual with a known mlh1 and mlh2 mutation in the family) for hereditary nonpolyposis colorectal cancer (hnpcc) genetic testing
10/01/2011
03/31/2012
S3833
Complete apc gene sequence analysis for susceptibility to familial adenomatous polyposis (fap) and attenuated fap
10/01/2011
S3834
Single-mutation analysis (in individual with a known apc mutation in the family) for susceptibility to familial adenomatous polyposis (fap) and attenuated fap
10/01/2011
S3835
Complete gene sequence analysis for cystic fibrosis genetic testing
10/01/2011
03/31/2012
S3837
Complete gene sequence analysis for hemochromatosis genetic testing
10/01/2011
03/31/2012
S3840
Dna analysis for germline mutations of the ret proto-oncogene for susceptibility to multiple endocrine neoplasia type 2
10/01/2011
S3841
Genetic testing for retinoblastoma
10/01/2011
S3842
Genetic testing for von hippel-lindau disease
10/01/2011
S3843
Dna analysis of the f5 gene for susceptibility to factor v leiden thrombophilia
10/01/2011
03/31/2012
S3844
Dna analysis of the connexin 26 gene (gjb2) for susceptibility to congenital, profound deafness
10/01/2011
S3845
Genetic testing for alpha-thalassemia
10/01/2011
S3846
Genetic testing for hemoglobin e beta-thalassemia
10/01/2011
S3847
Genetic testing for tay-sachs disease
10/01/2011
03/31/2012
S3848
Genetic testing for gaucher disease
10/01/2011
03/31/2012
S3849
Genetic testing for niemann-pick disease
10/01/2011
S3850
Genetic testing for sickle cell anemia
10/01/2011
S3851
Genetic testing for canavan disease
10/01/2011
03/31/2012
S3852
Dna analysis for apoe epilson 4 allele for susceptibility to alzheimer's disease
10/01/2011
S3853
Genetic testing for myotonic muscular dystrophy
10/01/2011
S3854
Gene expression profiling panel for use in the management of breast cancer treatment
10/01/2011
12/31/2015
S3855
Genetic testing for detection of mutations in the presenilin - 1 gene
10/01/2011
12/31/2014
S3860
Genetic testing, comprehensive cardiac ion channel analysis, for variants in 5 major cardiac ion channel genes for individuals with high index of suspicion for familial long qt syndrome (lqts) or related syndromes
10/01/2011
03/31/2012
S3861
Genetic testing, sodium channel, voltage-gated, type v, alpha subunit (scn5a) and variants for suspected brugada syndrome
10/01/2011
S3862
Genetic testing, family-specific ion channel analysis, for blood relatives of individuals (index case) who have previously tested positive for a genetic variant of a cardiac ion channel syndrome using either one of the above test configurations or confirmed results from another laboratory
10/01/2011
03/31/2012
S3865
Comprehensive gene sequence analysis for hypertrophic cardiomyopathy
10/01/2011
S3866
Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (hcm) in an individual with a known hcm mutation in the family
10/01/2011
S3870
Comparative genomic hybridization (cgh) microarray testing for developmental delay, autism spectrum disorder and/or mental retardation
10/01/2011
S3890
Dna analysis, fecal, for colorectal cancer screening
10/01/2011
12/31/2015
U0001
CDC 2019 novel coronavirus (2019-nCoV) real-time rt-pcr diagnostic panel
02/04/2020
U0002
2019-nCoV coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), Non-CDC
02/04/2020
U0003
Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R
04/14/2020
U0004
2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple
types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R
04/14/2020
Version Effective Date: 04/01/2020
Version Issued Date: 04/10/2020
Version Reissued Date: N/A



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