Aetna Lab Genetic Testing - Excel

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					     Page 1                                           OUTPATIENT LABORATORY MATRIX OF PAYORS CONTRACTED WITH GBMC, INC.                                                                        Printed on 9/29/2012
                                                                                                                                                                          983bf745-e88f-491f-a11d-a7adb6050c98.xls


                                  LABORATORY
                                          CONTRACTED LABORATORY NETWORKS




                                              QUEST




                                                         CORP.




                                                                       GBMC
                                                                        LAB
                                                          LAB
Insurance Company                                                                                                                            COMMENT

                                                                                  *See Note at bottom of page
Aetna: HMO, Elect Choice EPO, Aetna
                                                                                  Eff 7/1/07: Members must use QUEST or other PAR lab (not LabCorp)
Select, Open Access Aetna Select, Open      YES*         NO             NO
                                                                                  Eff 4/16/12: For All Aetna Members: USE QUEST for all Genetics Testing or members will pay more Out of Pocket. Call 1-866-
Access HMO, Open Access Elect Choice)
                                                                                  GENE-INFO.
                                                                              *See Note at bottom of page
Aetna: PPO, QPOS, Managed Choice POS,                                         Eff 7/1/07: Members must use QUEST or other PAR lab (not LabCorp)
Choice POS, Choice POS II, US Access,                                         Members have out of network benefits, however, Labs done @GBMC MUST BE PREAUTHORIZED, CAN'T GUARANTEE
                                            YES*         NO       SEE COMMENT
Open Access, Open Access Managed                                              HOSPITAL PAYMENT
Choice, Open Choice PPO                                                       Eff 4/16/12: For All Aetna Members: USE QUEST for all Genetics Testing or members will pay more Out of Pocket. Call 1-866-
                                                                              GENE-INFO.

                                                                                  EFF 7/1/07: NOTE: If members go to any lab other than Quest, their out of pocket costs will be more. Patients receiving
                                                                                  covered services from a nonparticipating provider are subject to out-of-network deductibles and coinsurance.
Aetna: Indemnity or Traditional Choice      YES*       See Note        YES
                                                                                  Eff 4/16/12: For All Aetna Members: USE QUEST for all Genetics Testing or members will pay more Out of Pocket. Call 1-866-
                                                                                  GENE-INFO.

                                                                                  *See Note at bottom of page
                                                                                  Eff 7/1/07: Members must use QUEST or other PAR lab (not LabCorp)
Aetna Golden Medicare (HMO)                 YES*         NO             NO
                                                                                  Eff 4/16/12: For All Aetna Members: USE QUEST for all Genetics Testing or members will pay more Out of Pocket. Call 1-866-
                                                                                  GENE-INFO.
                                                                              *See Note at bottom of page
                                                                              EFF 7/1/07: NOTE: If members go to any lab other than Quest, their out of pocket costs will be more. Patients receiving
                                                                              covered services from a nonparticipating provider are subject to out-of-network deductibles and coinsurance. Labs done @GBMC
Aetna Golden Choice (Medicare PPO)          YES*       See Note   SEE COMMENT
                                                                              SHOULD BE PREAUTHORIZED, CAN'T GUARANTEE HOSPITAL PAYMENT
                                                                              Eff 4/16/12: For All Aetna Members: USE QUEST for all Genetics Testing or members will pay more Out of Pocket. Call 1-866-
                                                                              GENE-INFO.
                                                                                  *See Note at bottom of page
                                           YES* eff                               GBMC Lab for approved services only, pre-auth req. Preauthorization will be required for members to access network hospital
AmeriGroup (Medicaid MCO)                                YES*     SEE COMMENT
                                            4/1/08                                outpatient departments for blood drawing and/or specimen collection and/or processing. Call 800-454-3730 Auth Forms available at:
                                                                                  www.amerigroupcorp.com/providers
                                                                              *See Note at bottom of page
                                                                              GBMC Lab for approved services only, pre-auth req. Preauthorization will be required for members to access network hospital
AmeriGroup AmeriVantage (Medicare          YES* eff                YES W/AUTH outpatient departments for blood drawing and/or specimen collection and/or processing.
                                                         YES*
Advantage Plans)                            4/1/08                SEE COMMENT Auth Forms available at: www.amerigroupcorp.com/providers
                                                                              Telephone 800-454-3730, (if urgent) 866-805-4589
                                                                              Fax: 1-800-964-3627
Beech Street PPO                                                                   VARIES BY PLAN/EMPLOYER GROUP, CALL MEMBER SERVICES # ON CARD
Bravo by Elder Health HMO                   YES*         NO             NO        *See Note at bottom of page
Care First Administrators (GBMC Health
                                             NO          NO            YES        Employees MUST use GBMC Lab or experience additional out-of-pocket expense.
Plan)
CareFirst BC/BS of MD: PPN/PPO              YES*         YES*     SEE COMMENT Members may use GBMC Lab with higher out of network cost, *See Note at bottom of page.
                                                                              *See Note at bottom of page
CareFirst BC/B of MD: MPOS                  YES*         YES*     SEE COMMENT
                                                                              Members may use GBMC Lab with higher out of network cost

CareFirst BlueChoice HMO & POS with NO
OPT-OUT (XIC, XIK, XWR, may have other       NO          YES*           NO        *See Note at bottom of page
Acct Specific Prefixes)




                  *Quest and LabCorp: For Routine Labs, can have specimen drawn here free of charge but must have lab order on a Physician provided Quest or LabCorp Req. form.
                                                                                For STAT: Must go to Quest or LabCorp
      Page 2                                              OUTPATIENT LABORATORY MATRIX OF PAYORS CONTRACTED WITH GBMC, INC.                                                                        Printed on 9/29/2012
                                                                                                                                                                              983bf745-e88f-491f-a11d-a7adb6050c98.xls


                                     LABORATORY
                                               CONTRACTED LABORATORY NETWORKS




                                                  QUEST




                                                             CORP.




                                                                          GBMC
                                                                           LAB
                                                              LAB
Insurance Company                                                                                                                                 COMMENT



CareFirst BlueChoice HMO Opt-Out or Open
Access (XIC, XIS, & others….Card will say                                             *See Note at bottom of page
                                                  NO         YES*      GET AUTH
OPEN ACCESS) Includes Balt County Triple                                              Members may use GBMC Lab with higher out of network cost
Option Plan (prefix BIO, BRN, CEG)

CareFirst BluePreferred PPO (XIP, XIL,                                           *See Note at bottom of page
XWV, may have other Acct Specific                YES*        YES*    SEE COMMENT Members may use GBMC Lab with higher out of network cost
Prefixes)                                                                        8/24/07: Per Karen Hudson/CF Rep: No Auth Needed
                                                                                 *See Note at bottom of page
CareFirst Indemnity (XIA, XIJ, XWY, may
                                                 YES*        YES*    SEE COMMENT Members may use GBMC Lab with higher out of network cost
have other Acct Specific Prefixes)
                                                                                 8/24/07: Per Karen Hudson/CF Rep: No Auth Needed
CareFirst MHIP BlueChoice                         NO         YES*          NO       *See Note at bottom of page
                                                                                    *See Note at bottom of page
CareFirst MHIP BluePreferred                     YES*        YES*    SEE COMMENT Members may use GBMC Lab with higher out of network cost
                                                                                    8/24/07: Per Karen Hudson/CF Rep: No Auth Needed
                                                                     CareFirst BC/BS NOTE: MUST VERIFY PTS. EMPLOYER GROUP
ChoiceCare Network (Humana)                                                          VARIES BY PLAN/EMPLOYER GROUP, CALL MEMBER SERVICES # ON CARD
Cinergy Health Plan                              YES         YES          YES
                                                                                    *See Note at bottom of page
                                                                                    Pure HMO members should NOT use our Outpatient Lab. If member has an opt-out and they are willing to pay additional out-of-
CIGNA/HMO                                        YES*        YES*    SEE COMMENT pocket expenses, they must sign a waiver.

                                                                                      HMO w/Opt-Out: May use GBMC lab but will pay more, can be billed.
                                                                                      *See Note at bottom of page
CIGNA/PPO & other Non-HMO Products               YES*        YES*    SEE COMMENT
                                                                                      May use GBMC lab but will pay more, can be billed.
                                                                                                                                        *See Note at bottom of page
Coventry: HMO                                                                                             No Auth Needed if performed at LabCorp or Quest, any other location requires Pre-Auth
                                                 YES*        YES*    SEE COMMENT
(formerly Principal HC)                                                                                                    EXCEPTION: CODE 93000 EKG, NO AUTH NEEDED
                                                                                                          No Paper Referrals, can also use Dianon Systems 800-328-2666, a subsidiary of LabCorp.
                                                                                                                                        *See Note at bottom of page
Coventry: PPO                                                                                             No Auth Needed if performed at LabCorp or Quest, any other location requires Pre-Auth
                                                 YES*        YES*    SEE COMMENT
(formerly Principal HC)                                                                                                    EXCEPTION: CODE 93000 EKG, NO AUTH NEEDED
                                                                                                          No Paper Referrals, can also use Dianon Systems 800-328-2666, a subsidiary of LabCorp.

                                                                                                                                           *See Note at bottom of page
                                                                                       Member must go through PCP before going for labwork. PCP must document referral in Pt's chart. Lab services performed at a non-
Coventry: Diamond Plan-Medicaid MCO
                                                 YES*        YES*    SEE COMMENT               participating facility (GBMC) will require prior authorization . No Auth Needed if performed at LabCorp or Quest
(formerly Principal HC)
                                                                                                                             EXCEPTION: CODE 93000 EKG, NO AUTH NEEDED
                                                                                                           No Paper Referrals, can also use Dianon Systems 800-328-2666, a subsidiary of LabCorp.

                                                                                       Same benefits as Medicare. Administered by EverCare. Member pays co-pay for each Medicare-covered clinical/diagnostic lab. No
Erickson Advantage (UHC Medicare Adv Plan       May pay
                                                             YES          YES                                                            Auth or PreCert needed
for residents of an Erickson Community)          more
                                                                                                                               www.ericksonadvantage.com (800-704-7839)
Evercare Plan IP (PPO) (UHC Medicare
                                                                                                                                        Same benefits as Medicare.
Advantage Plan) Plans for Medicare eligible     May pay
                                                             YES          YES                          See member's card for co-pay, may differ per plan type and service rendered, No Referrals needed
people living in contracted Evercare skilled     more
                                                                                                                                          www.evercareplans.com
nursing facilities
                                                                                                                                           *See Note at bottom of page
First Health                                     YES*        YES*    SEE COMMENT
                                                                                                                                            Check member's benefits



                     *Quest and LabCorp: For Routine Labs, can have specimen drawn here free of charge but must have lab order on a Physician provided Quest or LabCorp Req. form.
                                                                                   For STAT: Must go to Quest or LabCorp
     Page 3                                              OUTPATIENT LABORATORY MATRIX OF PAYORS CONTRACTED WITH GBMC, INC.                                                                              Printed on 9/29/2012
                                                                                                                                                                                   983bf745-e88f-491f-a11d-a7adb6050c98.xls


                                  LABORATORY
                                              CONTRACTED LABORATORY NETWORKS




                                                 QUEST




                                                              CORP.




                                                                              GBMC
                                                                               LAB
                                                               LAB
Insurance Company                                                                                                                                     COMMENT



Great West                                      YES*          YES*             YES                                          May also use Dianon Systems (888) 522-2677
                                                                                                                                           See directory
                                                                                                                                    *See Note at bottom of page
Helix Family Choice                             NO            YES*             NO
                                                                                                                       ANY SERVICES PERFORMED HERE WILL BE DENIED.
InforMed PPO                                                                                VARIES BY PLAN/EMPLOYER GROUP, CALL MEMBER SERVICES # ON CARD
JHHC EHP (POS Plan, Triple Option)              YES*          YES*             YES
                                                                                                                                               *See Note at bottom of page
                                                                               NO           Eff 7/15/05, PP cannot use GBMC LAB except for specific tests: SEE TEST EXCEPTION LIST sent to you on 6/24/05 & on next
JHHC Priority Partners (Medicaid MCO)           YES*          YES*
                                                                           w/exceptions                                                TAB . Pre-Auth Required. Call 410-762-5240.
                                                                                                           FOR MORE INFO CALL: Customer Service at 800-654-9728 or Care Management at 800-261-2421
                                                                                                                                               *See Note at bottom of page
                                                                               YES
JHHC Uniformed Services                         YES*           NO                                                   No referral required when using capitated provider or Johns Hopkins Medicine Lab.
                                                                           see Comment
                                                                                                                        When billed by a hospital, fax request to Central Intake 410-424-4603.
                                                                                                         **Home Centers approved to use GBMC: Charles Plaza, Severna Park, Towson, White Marsh, Woodlawn
KAISER PERMANENTE (all products
                                                YES*           NO          SEE COMMENT                                Outpatient laboratory services performed at GBMC must be pre-authorized.
including Kaiser Select)
                                                                                                                                             *See Note at bottom of page

                                                                                                                                              *See Note at bottom of page
Mail Handlers Benefit Plan (administered by               Yes*, but will                     QUEST Lab Savings Program: If member uses Quest for covered lab tests, on a Quest Req Form, and Quest bills them directly,
                                                YES*                           NO
Coventry/First Health)                                     pay more                           member does not need to file a claim and will have NO cost. Call 1-800-377-7220. Not covered:• Handling and administrative
                                                                                                   charges, • Routine lab services except as covered under Preventive care, • Professional fees for automated tests

                                                                                                                                        *See Note at bottom of page
Maryland Physicians Care                        YES*          YES*             NO
                                                                                                   GBMC does NOT have a contract with MPC. Members should call 1-800-953-8852 for complete list of Lab sites

MultiPlan/PHCS                                  YES*          YES*    SEE COMMENT                                               Per Benefit Plan, call # on back of card.
NCAS-CareFirst Administrators                                      SEE Members Card for PPO Network (could be CareFirst, Alliance/OneNet PPO, NCPPO, etc.) Follow rules for that network
NCPPO                                           YES*          YES*         YES
Three Rivers Provider Network (PPO)             YES           YES         YES*                 *Per Payor. These member can go anywhere, but may have a higher co-pay if using hospital, it's up to member
TRICARE PRIME                                   YES           YES          YES                                           GBMC considered In-Network, no extra cost to member
                                                                                                                  ***MDIPA AND OPT CHOICE CANNOT USE GBMC LAB 'EXCEPT FOR EKG'S'
                                                                                                        **EKG'S MAY BE PERFORMED AT THE GBMC LAB FOR ALL MDIPA, OPTIMUM CHOICE MEMBERS
                                                                               NO
                                                                                               Lab services for HMO may NOT be performed by outpatient hospital (GBMC) unless authorized by Clinical Care Coordination
                                                                                                                          Department, an emergency, or in conjunction with inpatient care.
                                                                              -but-
UHC: MAMSI Gated HMOs: MDIPA, Optimum
                                                NO            YES*
Choice (no out of ntwk benefits)                                                                                 Certain STAT labs can be done at GBMC, including Bilirubin for infants. No Auth Needed
                                                                               SEE
                                                                                                                           If ID Card indicates: LAB=LABCORP, the member MUST use Labcorp.
                                                                            COMMENT
                                                                                                        If ID Card indicates: LAB=PAR, member may use any participating outpatient commerical medical lab. See
                                                                                                                                         unitedhealthcareonline.com for complete list.


                                                                                               3/19/07: Per Karen DiGiovanni, Members CAN use GBMC's Lab. UHC tells members that they must use a Freestanding facility
UHC: MAMSI: POS MDIPA Preferred, OCI
                                                NO            YES*             YES            (LabCorp), but they WILL pay all the claims w/no extra cost to member for those who use GBMC Lab. Certain Lab tests are non-
Preferred (has out of ntwk benefits)
                                                                                                                                                 covered, call for benefits.
                                                                                               3/19/07: Per Karen DiGiovanni, Members CAN use GBMC's Lab. UHC tells members that they must use a Freestanding facility
UHC: MAMSI: (OneNet PPO and MAMSI               NO            YES*             YES            (LabCorp), but they WILL pay all the claims w/no extra cost to member for those who use GBMC Lab. Certain Lab tests are non-
Life/Health)                                                                                                                                     covered, call for benefits.



                  *Quest and LabCorp: For Routine Labs, can have specimen drawn here free of charge but must have lab order on a Physician provided Quest or LabCorp Req. form.
                                                                                          For STAT: Must go to Quest or LabCorp
     Page 4                                              OUTPATIENT LABORATORY MATRIX OF PAYORS CONTRACTED WITH GBMC, INC.                                                                  Printed on 9/29/2012
                                                                                                                                                                       983bf745-e88f-491f-a11d-a7adb6050c98.xls


                                   LABORATORY
                                              CONTRACTED LABORATORY NETWORKS




                                                 QUEST




                                                            CORP.




                                                                      GBMC
                                                                       LAB
                                                             LAB
Insurance Company                                                                                                                         COMMENT

                                                                                   3/19/07: Per Karen DiGiovanni, Members CAN use GBMC's Lab. UHC tells members that they must use a Freestanding facility
UHC: HMO (Choice, Choice Plus, Select,
                                                NO          YES*       YES        (LabCorp), but they WILL pay all the claims w/no extra cost to member for those who use GBMC Lab. Certain Lab tests are non-
Select Plus, CORE)
                                                                                                                                     covered, call for benefits.
                                                                                   3/19/07: Per Karen DiGiovanni, Members CAN use GBMC's Lab. UHC tells members that they must use a Freestanding facility
UHC: PPO & Indemnity: (Options PPO,
                                                NO          YES        YES        (LabCorp), but they WILL pay all the claims w/no extra cost to member for those who use GBMC Lab. Certain Lab tests are non-
Definity PPO, Definity Choice Plus)
                                                                                                                                     covered, call for benefits.
UHC: Community Plan (was AmeriChoice-
                                                NO          YES*       YES               7/11/08: Per Tammy Adams, Members CAN use GBMC's Lab. Certain Lab tests are non-covered, call for benefits.
Medicaid MCO)
                                                                                                                                  *See Note at bottom of page
                                                NO          YES*       NO
UHC: Primary Adult Care (PAC) ages 19+ only                                                                                      Lab Order needed, no referral
              SM
UHC: Definity Consumer-Driven Health
Plans
UHC: SecureHorizons & other Medicare
                                                NO          YES*       YES                                        Labcorp is preferred Lab, so member may pay more @GBMC
products (Golden Rule)
Universal Healthcare PPO & PFFS                 YES         NO        YES*               *May pay higher out of pocket, check benefits: www.univhc.com, PFFS: ph# 877-661-3920, PPO: 1-866-690-4842
                                                                                                                                   *See Note at bottom of page
U.S.A. Managed Care Organization                YES*        YES*       YES                                             See Directory for complete listing (www.usamco.com)
                                                                                                                               Benefits may vary, check with plan.




                   *Quest and LabCorp: For Routine Labs, can have specimen drawn here free of charge but must have lab order on a Physician provided Quest or LabCorp Req. form.
                                                                              For STAT: Must go to Quest or LabCorp
Priority Partners Lab Initiative
Lab codes excluded from Lab Carve-Out Policy - Outpatient Hospital Setting payables
Implementation Date - July 15, 2005

CPT Code CPT Description
80195 Sirolimus
80400 acth stim
80402 21 hydroxylase def
80406 3 beta-hydroxydehydrogenase deficiency
80408 aldosterone suppression
80410 calcitonin stim
80412 evocative/suppression testing
80414 evocative/suppression testing
80415 evocative/suppression testing
80416 evocative/suppression testing
80417 evocative/suppression testing
80418 evocative/suppression testing
80420 evocative/suppression testing
80422 evocative/suppression testing
80424 evocative/suppression testing
80426 evocative/suppression testing
80428 evocative/suppression testing
80430 evocative/suppression testing
80432 evocative/suppression testing
80434 evocative/suppression testing
80435 evocative/suppression testing
80436 evocative/suppression testing
80438 evocative/suppression testing
80439 evocative/suppression testing
80440 evocative/suppression testing
80500 path clinical consultation
80502 path clinical consultation- complex
81000 Urinalysis
81002 Routine Urinalysis w/o Microscopy
81015 Urinalysis, Microscopy Only
81025 Urine Pregnancy Test, by Visual Color Comparison
82106 alfa-fetoprotein amniotic fluid
82107 AFP-L3 FRACTION ISOFORM AND TOTAL AFP
82135 ASSAY, AMINOLEVULINIC ACID
82140 ASSAY OF AMMONIA
82143 AMNIOTIC FLUID SCAN
82270 Blood, Occult; Feces Screen
82271 Blood, occult, by peroxidase activity (eg. Guaiac), qualitative, feces, single specimen (eg, from digital rectal
82272 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources
82435 Chloride; blood
82731 fetal fibronectin semiquantitative
82948 Glucose, Blood Reagent Strip
82962 Glucose, Blood by Glucose Monitoring Device
83631 Lactoferrin, fecal; quantitative
83661 l/s ratio fetus
83663 fluorescence polarizaion
83873 csf myelin basic protein
Priority Partners Lab Initiative
Lab codes excluded from Lab Carve-Out Policy - Outpatient Hospital Setting payables
Implementation Date - July 15, 2005

CPT Code CPT Description
83883 pephrelometry, each analyte
83900 Molecule Nucleic AMPLI 2 seq
83907 Molecular diagnostics; lysis lof cells prior to nuceic acid extractiom (eg, stool specimens, parraffin
83908 Molecular diagnostics; signal amplification of patient nucleic acid, each nucleic acid sequence
83909 Molecular diagnostics; separation and identification by high resolution technique (eg, capillary
83914 Mutation identification by enzymatic ligation or primer extension, single segment, each segment (eg,
oligonucleotide ligation assay (OLA), single base chain extension (SBCE), or allele-specific primer extension
83986 Assay Body Fluid Acidity
84081 phosphatidyl glycerol (amniotic fluid enzyme test)
84315 specific gravity - other than urine
85002 bleeding time
85013 Blood Count, Spun Microhematocrit (HCT)
85018 Blood Count, Hemoglobin (Hgb)
85097 Bone Marrow
85460 kleihauer Betke test
85540 Opened Stain
86200 Cyclic citrullinated peptife (CCP), antibody
86308 Heterophile Antibodies Screening
86355 Immunofixation electrophoresis; other fluids with concentration (eg, urine, CSF)
86357 Natural killer (NK) cells, total count
86367 Stem cells (ie, CD34), total count
86480 Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response
86485 skin test
86490 skin test
86510 skin test
86580 skin test
86805 Tissue Typing - lymphocyte assay
86806 tissue typing
86807 tissue typing
86808 tissue typing
86812 tissue typing
86813 tissue typing
86816 tissue typing
86817 tissue typing
86821 tissue typing
86822 tissue typing
86849 tissue typing
86880 Antihuman Globulin Test
86885 ¨ Indirect, Qualitative, Each Antiserum
86886 ¨ Indirect, Titer, Each Antiserum
86890 Autologous Blood or Component, Collecting Processing & Storage
86891 Intra- or Postoperative Salvage
86900 Blood Typing If Part Of Transfusion
86901 ¨ Rh (D)
86903 ¨ Antigen Screening For Compatible Blood Unit Using Reagent Serum
86904 ¨ Antigen Screening For Compatible Unit Using Patient Serum
86905 ¨ RBC Antigens, Other Than ABO or RH (D)
Priority Partners Lab Initiative
Lab codes excluded from Lab Carve-Out Policy - Outpatient Hospital Setting payables
Implementation Date - July 15, 2005

CPT Code CPT Description
86906 ¨ Rh Phenotyping, Complete
86922 Transfusion medicine compatibility testing
86923 Compatibility test each unit; electronic
86927 Fresh Frozen Plasma, Thawing
86930 Frozen Blood, Each Unit, Freezing (Includes Preparation)
86931 Thawing
86940 Hemolysis and Agglutinins; Auto, Screen
86941 Incubated
86945 Incubation Of Blood Product
86950 Leukocyte Transfusion
86960 Volume reduction of blood or blood product (eg, red blood cells or platelets), each unit
86965 Pooling Of Platelets Or Other Blood Products
86970 Pretreatment of RBC’s For Use In RBC Antibody Detection
86971 Incubation With Enzymes
86972 By Density Gradient Separation
86975 Pretreatment Of Serum For Use In RBC Antibody Identification
86976 By Dilution
86977 Incubation With Inhibitors
86978 By Differential Red Cell Absorption Using Patient RBC’s
86985 Splitting Of Blood or Blood Products
86999 Unlisted Transfusion Medicine Procedure
87001 Animal Inoculation, Small Animal, With Observation
87003 Animal Inoculation, Small Animal, With Observation And Dissection
87015 SPECIMEN CONCENTRATION
87045 FECES CULTURE, BACTERIA
87046 STOOL CULTR, BACTERIA, EACH
87070 CULTURE, BACTERIA, OTHER
87071 CULTURE BACTERI AEROBIC OTHR
87073 CULTURE BACTERIA ANAEROBIC
87076 CULTURE ANAEROBE IDENT, EACH
87081 CULTURE SCREEN ONLY
87101 SKIN FUNGI CULTURE
87102 FUNGUS ISOLATION CULTURE
87106 FUNGI IDENTIFICATION, YEAST
87107 FUNGI IDENTIFICATION, MOLD
87109 MYCOPLASMA
87110 CHLAMYDIA CULTURE
87116 MYCOBACTERIA
87118 MYCOBACTERIC IDENTIFICATION
87140 CULTURE TYPE IMMUNOFLUORESC
87143 CULTURE TYPING, GLC/HPLC
87147 CULTURE TYPE, IMMUNOLOGIC
87149 CULTURE TYPE, NUCLEIC ACID
87152 Identification By Pulse Field Gel Typing
87158 CULTURE TYPING, ADDED METHOD
87172 PINWORM EXAM
87176 TISSUE HOMOGENIZATION, CULTR
Priority Partners Lab Initiative
Lab codes excluded from Lab Carve-Out Policy - Outpatient Hospital Setting payables
Implementation Date - July 15, 2005

CPT Code CPT Description
87177 Ova and Parasites, Direct Smears, Concentration and ID
87181 MICROBE SUSCEPTIBLE, DIFFUSE
87184 MICROBE SUSCEPTIBLE, DISK
87185 MICROBE SUSCEPTIBLE, ENZYME
87186 MICROBE SUSCEPTIBLE, MIC
87187 MICROBE SUSCEPTIBLE, MLC
87190 MICROBE SUSCEPT, MYCOBACTERI
87197 BACTERICIDAL LEVEL, SERUM
87205 SMEAR, GRAM STAIN
87206 SMEAR, FLUORESCENT/ACID STAI
87207 SMEAR, SPECIAL STAIN
87209 Smear, primary source with interpretation; complex special stain (eg, trichrome, iron hemotoxylin) for ova
87210 Wet Mount For Infectious Agents (Eg. Saline, India Ink, KOH Preps)
87220 Tissue Exam By KOH Slide Of Samples
87230 ASSAY, TOXIN OR ANTITOXIN
87250 VIRUS INOCULATE, EGGS/ANIMAL
87252 VIRUS INOCULATION, TISSUE
87253 VIRUS INOCULATE TISSUE, ADDL
87254 VIRUS INOCULATION, SHELL VIA
87255 GENET VIRUS ISOLATE, HSV
87265 PERTUSSIS AG, IF
87270 CHLAMYDIA TRACHOMATIS AG, IF
87274 HERPES SIMPLEX 1, AG, IF
87276 INFLUENZA A, AG, IF
87280 RESPIRATORY SYNCYTIAL AG, IF
87281 PNEUMOCYSTIS CARINII, AG, IF
87285 TREPONEMA PALLIDUM, AG, IF
87299 ANTIBODY DETECTION, NOS, IF
87300 AG DETECTION, POLYVAL, IF
87301 ADENOVIRUS AG, EIA
87305 IAAD EIA QUAL/SEMIQUAN MULTIPLE STEP ASPERGILLUS
87320 CHYLMD TRACH AG, EIA
87324 CLOSTRIDIUM AG, EIA
87327 CRYPTOCOCCUS NEOFORM AG, EIA
87328 CRYPTOSPORIDIUM AG, EIA
87329 GIARDIA AG, EIA
87335 E COLI 0157 AG, EIA
87338 HPYLORI, STOOL, EIA
87350 HEPATITIS BE AG, EIA
87380 HEPATITIS DELTA AG, EIA
87385 HISTOPLASMA CAPSUL AG, EIA
87390 HIV-1 AG, EIA
87400 INFLUENZA A/B, AG, EIA
87420 RESP SYNCYTIAL AG, EIA
87425 ROTAVIRUS AG, EIA
87427 SHIGA-LIKE TOXIN AG, EIA
87430 STREP A AG, EIA
Priority Partners Lab Initiative
Lab codes excluded from Lab Carve-Out Policy - Outpatient Hospital Setting payables
Implementation Date - July 15, 2005

CPT Code CPT Description
87449 AG DETECT NOS, EIA, MULT
87490 CHYLMD TRACH, DNA, DIR PROBE
87491 CHYLMD TRACH, DNA, AMP PROBE
87498 IADNA ENTEROVIRUS AMPLIFIED PROBE TECHNIQUE
87529 HSV, DNA, AMP PROBE
87530 HSV, DNA, QUANT
87555 M.TUBERCULO, DNA, DIR PROBE
87581 M.PNEUMON, DNA, AMP PROBE
87590 N.GONORRHOEAE, DNA, DIR PROB
87591 N.GONORRHOEAE, DNA, AMP PROB
87621 HPV, DNA, AMP PROBE
87640 IADNA S. AUREUS AMP PRB TQ
87641 IADNA S. AUREUS METHICILLIN RESISTANT AMP PRB TQ
87650 STREP A, DNA, DIR PROBE
87653 IADNA STREPTOCOCCUS GROUP B AMPLIFIED PROBE TQ
87797 DETECT AGENT NOS, DNA, DIR
87799 DETECT AGENT NOS, DNA, QUANT
87801 DETECT AGNT MULT, DNA, AMPLI
87802 STREP B ASSAY W/OPTIC
87803 CLOSTRIDIUM TOXIN A W/OPTIC
87804 INFLUENZA ASSAY W/OPTIC
87808 IAADIADOO TRICHOMONAS VAGINALIS
87810 CHYLMD TRACH ASSAY W/OPTIC
87880 Infectious Agent Detection by Immunoassay w/ Direct Optional Observation; Streptococcus, Group A
87899 AGENT NOS ASSAY W/OPTIC
87900 Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics
87999 MICROBIOLOGY PROCEDURE
88108 Cytopathology, Concentration Technique, Smears And Interpretation
88112 Selective Cellular Enhancement Technique
88125 Forensic
88130 Sex chromatin identification; Barr bodies
88141 Cytopathology,cervical or vaginal (any reporting system), requiring interpretation by physician
88142 Cytopathology, Slides, Cervical Or Vaginal
88143 Cytopathology, Slides, Cervical Or Vaginal
88147 Cytopathology, Slides, Cervical Or Vaginal
88148 Cytopathology, Slides, Cervical Or Vaginal
88150 Cytopathology, Slides, Cervical Or Vaginal
88152 Cytopathology, Slides, Cervical Or Vaginal
88153 Cytopathology, Slides, Cervical Or Vaginal
88154 Cytopathology, Slides, Cervical Or Vaginal
88155 Cytopathology, Slides, Cervical Or Vaginal
88160 Cytopathology, smears, any other sources; screening and interpretation
88161 Preparation, screening and interpretation
88162 Extended study involving over 5 slides and/or multiple stains
88164 Cytopathology, Slides, Cervical Or Vaginal
88165 Cytopathology, Slides, Cervical Or Vaginal
88166 Cytopathology, Slides, Cervical Or Vaginal
Priority Partners Lab Initiative
Lab codes excluded from Lab Carve-Out Policy - Outpatient Hospital Setting payables
Implementation Date - July 15, 2005

CPT Code CPT Description
88167 Cytopathology, Slides, Cervical Or Vaginal
88172 Cytopathology, Slides, Cervical Or Vaginal
88173 Interpretation and report
88174 Cytopathology, Slides, Cervical Or Vaginal
88175 Cytopathology, Slides, Cervical Or Vaginal
88199 Unlisted cytopathology procedure
88300 Surgical Path gross exam - if done w/surgical procedure in hospital
88302 Surgical Path gross exam - if done w/surgical procedure in hospital
88304 Surgical Path gross exam - if done w/surgical procedure in hospital
88305 Surgical Path gross exam - if done w/surgical procedure in hospital
88307 Surgical Path gross exam - if done w/surgical procedure in hospital
88309 Surgical Path gross exam - if done w/surgical procedure in hospital
88311 Decalcification Procedures
88312 Opened Stain
88313 special stain
88314 frozen section
88321 Consultation And Report On Referred Slides Prepared Elsewhere
88323 Pathology Review
88325 surgical path - consultation and review of materials
88329 Pathology Consultation During Surgery
88331 surgical path
88332 surgical path
88333 Cytologic examination (eg, touch prep, squash prep), each additional site
88334 Cytologic examination (eg, touch prep, squash prep), each additional site
88342 surgical path
88346 surgical path
88347 surgical path
88348 Electron Microscopy, Diagnostic
88349 surgical path
88355 surgical path
88356 surgical path
88358 surgical path
88360 surgical path
88361 surgical path
88362 surgical path
88365 surgical path
88367 surgical path
88368 surgical path
88371 surgical path
88372 surgical path
88380 surgical path
88384 Array-based evaluation of multiple molecular probes; 11 through 50 probes
88385 Array-based evalutation of multiple molecular probes; 51 through 250 probes
88381 MICRODISSECTION PREP IDENTIFIED TARGET MANUAL
88386 Array-based evaluation of multiple molecular probes; 251 through 500 probes
88399 surgical path
88400 Bilirubin, Total, Transcutaneous
Priority Partners Lab Initiative
Lab codes excluded from Lab Carve-Out Policy - Outpatient Hospital Setting payables
Implementation Date - July 15, 2005

CPT Code CPT Description
89049 Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), Initial site
89050 cell count - body fluid
89051 cell count - body fluid
89060 crystal id by light microscopy any body fluid
89100 duodenal intubation and aspiration
89105 pancreatic or gall bladder specimen collection
89130 gastric intubation and aspiration
89132 gastric intubation and aspiration
89135 gastric intubation and aspiration
89136 gastric intubation and aspiration
89140 gastric intubation and aspiration
89141 gastric intubation and aspiration

				
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