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In house laboratory CPT code list

All In-Office Laboratory Testing and Procedures:

Marked with *, **, ***, ****, and ***** will be limited to one procedure within the same family of asterisks, per visit.

Example: All laboratory testing/procedure codes that are marked with one * will only be allowed to have one laboratory test/procedure performed, per visit, out of all of the codes designated with the single *.

Marked with the # symbol will only be considered for reimbursement if the member has an infertility benefit and the provider has the appropriate specialty. Refer to the policy titled Infertility Diagnosis and Treatment for additional information related to infertility coverage.

CPT Code Description

Primary Care Physicians and Specialists

80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when
performed, per date of service

80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when
performed, per date of service

81000* Urinalysis, non-automated, with microscopy

81001* Urinalysis, automated, with microscopy

81002* Urinalysis, non-automated, without microscopy

81003* Urinalysis, automated, without microscopy

81025 Urine pregnancy test, by visual color comparison methods

82270***** Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection)

CPT Code Description

Hematologists/Oncologists/Pediatric Hematologists

85097 Bone marrow; smear interpretation only, with or without differential cell count

86077 Blood bank physician services; difficult cross-match and/or evaluation of irregular antibody(s), interpretation and written report

86078 Blood bank physician services; investigation of transfusion reaction, including suspicion of transmissible disease, interpretation and written report

86079 Blood bank physician services; authorization for deviation from standard bloodbanking procedures, with written report

86927-86999 Transfusion medicine Ophthalmologists and Connecticut CLIA Certified Optometrists

Note: Connecticut optometrists may be reimbursed for CPT code 83861 in the office if they are CLIA Certified (Clinical Laboratory Improvement Amendments of 1988 (CLIA)). If no CLIA certification is on file, the service is not eligible for reimbursement.

83861 Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity

Ophthalmologists and Optometrists

83516 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method

87809 Infectious agent antigen detection by immunoassay with direct optical observation; adenovirus

Pulmonologists 82803 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation)
Rheumatologists

89060 Crystal Identification by light microscopy with or without polarizing lens analysis; tissue or any body fluid (except urine) Urologists

89264# Sperm identification from testis tissue, fresh or cryopreserved

89300 Semen analysis; presence and/or motility of sperm including Huhner test (post coital)

89310 Semen analysis; motility and count (not including Huhner test)

89320 Semen analysis; volume, count, motility and differential

89321 Semen analysis; sperm presence and motility of sperm, if performed

89322 Semen analysis; volume, count, motility, and differential using strict morphologic criteria (e.g., Kruger)

REIMBURSEMENT GUIDELINES

In-Office Laboratory Testing and Procedures

Reimbursement of network physicians for the performance of in-office laboratory testing/procedures is limited to those codes listed on the in-office laboratory testing and procedures list. Reimbursement for some of the Laboratory testing/procedures is limited to certain physician specialties. Refer to the Applicable Codes section below for a list of specific CPT codes.

Marked with a # symbol, will only be considered for reimbursement if the member has an infertility benefit and the provider has the appropriate specialty. Refer to the policy titled Infertility Diagnosis and Treatment for additional information related to infertility coverage.

Specimen Handling and Venipuncture CODE 36415

When specimen handling and venipuncture codes are billed;

With a laboratory/procedure code on the in-office laboratory testing and procedures list, only the laboratory testing/procedure and venipuncture codes will be considered for reimbursement. Note: The laboratory testing/procedure code will only be considered for reimbursement if the code is listed in the Applicable Codes section of the policy and the provider has the appropriate specialty, if required.

Without a laboratory testing/procedure code on the in-office laboratory testing and procedures list or with other non-laboratory testing/procedure services, the specimen handling and venipuncture codes will be considered for reimbursement.

CPT CODE 87880, 87561 - strep test

CPT CODE and description

87880 - Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A - average fee amount - $20 - $30

87561 - Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe technique

Coding for Reflex Testing

Some clinicians may desire to use both rapid immunoassay and molecular Strep A testing methods in a reflex testing scheme. This scheme is analogous to reflexing a rapid immunoassay to culture in which the molecular test is used in place of culture. For example, the initial test might be performed with a rapid immunoassay and then reflexed to molecular if the immunoassay results are negative but clinical signs suggest Strep A infection.

While the codes described above apply separately to these different testing technologies, both are Strep A tests. There is a Correct Coding Initiative (CCI) edit for CPT® 87880 and 87651. This CCI edit CANNOT be overcome by a modifier. Therefore, for Medicare and any other payer that utilizes CCI edits, billing for both tests of this reflex testing scheme is not permitted.

Coding for CPT® 87880 and 87651 may be permitted by some non-Medicare payers if they do not utilize CCI edits. Providers should contact non-Medicare payers to determine whether billing for both CPT® 87880 and 87651 is permitted.

Note that ordering clinicians must be aware of any reflex testing policy by a laboratory and should only order reflex testing if medically reasonable and necessary

Coding Summary

Test CLIA Payer CPT® Coding

Rapid Immunoassay

Acceava®, BinaxNOW®, or Clearview® brands or other Strep A tests manufactured by Alere

Waived Medicare 87880QW

Waived Non-Medicare 87880

Amerigroup Reminder: We Cover Rapid Strep Tests

Reminder: Rapid strep tests billed with CPT code 87880 are covered. This test should be completed for any child prescribed an antibiotic for pharyngitis

What this means to you: For your information only. No immediate action is necessary

Background

As part of our annual Healthcare Effectiveness Data and Information Set (HEDIS) audit, we assess appropriate testing for children with pharyngitis. The Centers for Disease Control and Prevention and the National Committee for Quality Assurance guidelines constitute the basis for this HEDIS measure.

As part of our audit, we review members’ medical records, claims and laboratory data.

During our last audit, many of you said Amerigroup Community Care does not reimburse for rapid strep tests; therefore, you don’t file claims for this service.

We want you to know Amerigroup does cover the rapid strep test when you file a claim using CPT code 87880. Pharyngitis can be validated through lab results; therefore, it serves as an indicator of appropriate antibiotic use. Attached is a summary sheet for this measure and the appropriate codes to use for diagnosis and payment.

We know many parents and guardians request or insist on antibiotics when they aren’t necessary for treatment. We count on your excellent training and cooperation to comply with this standard for appropriate antibiotic use.

Billing example

Mrs. x’ Visit

• Physician Visit – CPT 99202

• Nursing Work – CPT – (Office)

• Rapid Strep – CPT 87880

• All Linked to ICD-9 Code 462 (Pharyngitis)

Payments

• Medicare Pays $36.8729 per RVU

– 1.73 RVUs X 36.8729 = $63.790117

– Rapid Step (CPT 87880) = $16.01

• Total Payment From Medicare = $79.80

Strep Antigen Test List

Abbott Signify Strep A Dipstick Innovacon 87880QW
Abbott Signify Strep A Test Wyntek 87880QW
Acceava Strep A Twist Rapid Test Innovacon 87880QW
Acceava Strep A Test Innovacon 87880QW
Accustrip Strep A Princeton Biomeditech Corp 87880QW
Acon Strep A Rapid Strip Test Acon 87880QW
Acon Strep A Twist Rapid Test Acon 87880QW
Alere, Strep A, Alere I Instrument Alere Scarborough, Inc 87880QW
Applied Biotech SureStep Strep A (II) Applied Biotech, Inc 87880QW
Applied Biotech SureStep Strep A Exact Applied Biotech, Inc 87880QW
BD Veritor System for Rapid Detection of Group A Strep Becton Dickinson & Co. 87880QW
Beckman Coulter ICON DS Strep A Test Princeton BioMeditech 87880QW
Beckman Coulter ICON FX Strep A Test (formerly SmithKline) Binax 87880QW
Beckman Coulter Primary Care Diagnostics ICON DS Strep A Test Acon Laboratories 87880QW
Beckman Coulter Primary Care Diagnostics ICON SC Strep A Test Acon Laboratories 87880QW
Beckman Coulter Primary Care Diagnostics ICON FX Strep A
Immunochemical Strep A Antigen Test Beckman Coulter, Inc. 87880QW
Becton Dickinson Chek Group A Strep Test Innovacon, Ind 87880QW
Becton Dickinson LINK 2 Strep A Rapid Test Becton Dickinson 87880QW
Binax Clearview Advanced Strep A Binax, Inc 87880QW
Binax NOW Strep A Test Binax, Inc 87880QW
BioStar Acceava Strep A Test BioStar 87880QW
Biotechnostix Rapid Response Strep A Rapid Test Devise/Strip Acon Laboratories 87880QW
BTNX Rapid Response Strep A Rapid Test Strips Sa Scientific, Inc 87880QW
Cardinal Health SP Brand Rapid Test Strep A Dipstick / Rapid Test
Strep A Cassette Applied Biotech, Inc. 87880QW
Cardinal Health Strep A Cassette and Dipstick-Rapid Test Alere Sd 87880QW
Clearview Strep A Exact Dipstick Applied Biotech, Inc. 87880QW
CLIA Waived Inc Rapid STREP A Test Sa Scientific Inc 87880QW
Consult Diagnostics STREP A Rapid Dipstick Innovacon, Inc 87880QW
CTMI Strep A Rapid Test Strip Innovacon, Ind 87880QW
DE Healthcare Products, TruView Strep A Test / Strep A Cassette DE Healthcare Products 87880QW
Diagnostic Test Group Clarity Strep A Rapid Test Strips Princeton BioMeditech Corp 87880QW
Fisher HealthCare Sure-Vue Strep A (direct from throat) Applied Biotech, Inc. 87880QW
Genzyme Contrast Strep A Genzyme Diagnostics 87880QW
Genzyme OSOM Ultra Strep A Test (25 test kit) Genzyme Diagnostics 87880QW
Germaine Laboratories StrepAim Rapid Dipstick Test (Strep Group
A) Acon Laboratories, Inc. 87880QW
Germaine Laboratories Strep AIM Tower Acon Laboratories, Inc. 87880QW
Henry Schein Inc, OneStep+ Strep A Test / OneStep+ Strep A
Dipstick Test / OneStep+ Strep A Cassette Test / OneStep Pro+ Henry Schein, Inc 87880QW
ICON DS Strep A Test ACON Laboratories, Inc. 87880QW
IMI Signify Strep A Dipstick Innovacon Inc 87880QW
Immunostics Detector Strep A Direct ACON Laboratories, Inc. 87880QW
Immunostics Immuno/StrepA Detector ACON Laboratories, Inc. 87880QW
Instant Tech iStrep One Step Strep A Test ACON Laboratories, Inc. 87880QW
Inverness Med BioStar Acceava Strep A Test ACON Laboratories, Inc. 87880QW
Inverness Med BioStar Acceava Strep A Twist Innovacon, Inc 87880QW
Inverness Medical Clearview Strep A Exact II Dipstick Innovacon, Inc. 87880QW
Inverness Medical Signify Strep A Cassette Innovacon, Inc 87880QW
Jant Pharmacal AccuStrip Strep A (II) Jant Pharmacal 87880QW
Jant Pharmacal AccuStrip Strep A Value+ Test Strip Innovacon 87880QW
Jant Pharmacal Accutest Integrated Strep A Rapid Test Device Jant Pharmacal 87880QW
Jant Pharmacal Clinipak Strep A Rapid Test Strip Jant Pharmacal 87880QW
Laboratory Supply Company (LSC) PEP Strep A Cassette / PEP
Strep A Dipstick Test Acon Laboratories Co 87880QW
LABSCO Advantage Strep A Princeton BioMediTech Corp 87880QW
Roche Molecular, cobas Liat System IQuum, Inc. 87880QW
LifeSign LLC Status Strep A Princeton BioMediTech Corp 87880QW
Mainline Confirms Strep A Dots Test Mainline Technology, Inc 87880QW
McKesson Consult Diagnostics Strep A Test Dipstick Alere 87880QW
McKesson Medi-Lab Performance Strep A Test Dipstick/Cassette Applied Biotech, Inc. 87880QW
McKesson Medi-Lab Strep A Test Dipstick Innovacon, Inc. 87880QW
McKesson Medi-Lab Strep A Test – Twist Innovacon, Inc. 87880QW
McKesson Strep A Test Dipstick/Cassette Applied Biotech, Inc. 87880QW
Medline Strep A Test Strips {Throat Swabs} Alere, INC. 87880QW
MediLab Performance Strep A Twist Rapid Test MediLab 87880QW
Meridian Diag. ImmunoCard STAT Strep A Meridian Diagnostics 87880QW
Moore Medical The Supply Experts Strep A Test – Cassette Innovacon, Inc 87880QW
Moore Medical The Supply Experts Strep A Rapid Test – Dipstick Innovacon 87880QW
Mooremedical Strep A Rapid Test – Dipstick Alere San Diego Inc 87880QW
PEP Performance Enhanced Products Strep A Cassette Test /
Strep A Dipstick Acon Laboratories 87880QW
PerMaxin Rediscreen Strep A Rapid Test Acon Laboratories 87880QW
PerMaxin Rediscreen Strep A Twist Cassette Innovacon 87880QW

Polymedco, Inc. Poly Stat A (II) for Group A Strep [direct from throat swab] Applied Biotech, Inc. 87880QW
Poly stat Strep A Flip Test Princeton BioMediTech Corp 87880QW
Poly stat Strep A Strip Test Princeton Biomeditech Corp 87880QW
Polymedco Poly Stat Strep A Dipstick Innovacon 87880QW
Polymedco Poly Stat Strep A Liquid Test Polymedco 87880QW
Princeton BioMediTech BioStrep A Test Princeton BioMediTech Corp 87880QW
Princeton Biomeditech Status First Strep A Princeton BioMediTech Corp 87880QW
ProAdvantage by NDC Strep A Test Innovacon 87880QW
PSS Consult Diagnostics Strep A Dipstick Innovacon 87880QW
PSS World Medical Select Diagnostics Strep A Dipstick Innovacon 87780QW
PSS World Medical Select Diagnostics Strep A Twist Innovacon 87780QW
Quidel QuickVue Dipstick Strep A Quidel 87880QW
Quidel QuickVue In-Line Strep A Quidel 87880QW
Quidel QuickVue In-Line One-Step Strep A Quidel 87880QW
Quidel Sofia Strep A+ FIA (from throat swab only) Quidel Corp 87880QW
RAC Medical Clarity Strep A Twist Rapid Strep Test Device/Strip Acon laboratories, Co 87880QW
SMC Direct, LLC, RefuAH Strep A Rapid Wondfo Biotech Co., LTD. 87880QW
Remel RIM A.R.C. Strep A Test (direct from throat swab) Applied Biotech, Inc. 87880QW
SA Scientific SAS Strep A (direct from throat swab) SA Scientific, Inc. 87880QW
Sacks Medical Refuah Strep A Rapid Test Acon Laboratories 87880QW
StatusFirst Strep A Princeton BioMeditech Corp 87880QW
Select Medical Products Brand Rapid Test Strep A Dipstick Innovacon, Inc 87880QW
Sekisui Diag OSOM Strep A Test (direct throat swab) Sekisui Diagnostics 87880QW
Sekisui Diag OSOM Ultra Strep A Test Sekisui Diagnostics 87880QW
Select Medical Products Brand Rapid Test Strep A Twist Innovacon, Inc 87880QW
Signify Strep A Dipstick Applied Biotech, Inc. 87880QW
SmithKline ICON Fx Strep A Test (from throat swab only) Binax 87880QW
Stanbio Laboratory E-Z Well Strep A Rapid Device Test Acon Laboratories Co 87880QW
Stanbio Qustick Strep A Acon Laboratories Co 87880QW
StrepAim Princeton Biomeditech Corp 87880QW
Wondofo One Step Strep A Swab Test Guangzhou Wondfo Biotech Co., LTD. 87880QW
Wyntek Diagnostics OSOM Strep A Test Wyntek Diagnostics, Co 87880QW
Wyntek Diagnostics OSOM Ultra Strep A Test Wyntek Diagnostics, Co 87880QW

CPT code 86485, 86480, 86490, 86580 - Tb test

CPT CODE AND Description

86485 - Skin test; candida
86490 - Skin test; coccidioidomycosis - Average Fee amount $65 - $90
86580 - Skin test; tuberculosis, intradermal - Average Fee amount $7 - $10

ALL CPT required CLIA. Recently Medicare Excluded these CPTs from CLIA Edits

TB Testing – CPT 86580 / ICD9 V74.1

• Since the test is an inoculation screening test, rather than a vaccination, the test includes administering the skin test and you should not code separately for the administration.

• The Resource Based Relative Value System (RBRVS) does not include costs for a reading.

• Patients who do not show a response to the test may never return for a reading so this nurse “reading” cost is not included in the RVUs for 86580.

• If the patient does return for a reading, you may code 99211 for the nurse reading. Make sure to document appropriately

Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) Bundling Update

UnitedHealthcare Community Plan has received additional clarification from Arizona Health Care Cost Containment System (AHCCCS) regarding Tuberculosis Testing services (86580) included in the EPSDT visit. The AHCCCS Medical Policy Manual, Chapter 400, Policy 430, contains language specifically related to lab testing:

Payment for laboratory services that are not separately billable and considered part of the payment made for the EPSDT visit include, but are not limited to: 99000, 36415, 36416, 36400, 36406, and 36410. In addition, payment for all laboratory services must be in accordance with limitations or exclusions specified in AHCCCS health plan contract with the providers1.

Since CPT 86580 falls under Pathology/Laboratory services and is not included in those codes listed above, services using CPT 86580 during the EPSDT visit should be billed and processed separately according to the AHCCCS provider contract.

UnitedHealthcare Community Plan will reflect these changes by March 24, 2015. Any claims previously denied or recovered prior to this correction being implemented will be adjusted to process appropriately according to this new guidance.

Guidelines

1. Currently, CPT Code 86485* - Skin test; Candida – is the code available for the cost of the CANDIN and materials used in the skin test. This code does not include possibly related procedures such as office visits, injection, reading, or patient consultation.

3. Submit reasonable and necessary charges in accordance with, along with the current CPT Code. (current CANDIN estimated price per test is $14.90**).

4. The insurance company may ask for a copy of the invoice for the purchase of CANDIN in order to confirm the price.

Laboratory and Venipuncture Services Bundled Example: If procedure code 80047 (PCTC IND of 9 ) or 86485 (PCTC IND of 3) is reported with a facility place of service, the line item will deny.

Do you know how to code for a PPD/TB Skin Test? Proper coding for this test is quite simple. CPT 86580 is described as Skin Test; tuberculosis, intradermal and includes the administration of the test; therefore, do not attempt to bill any type of administration code in conjunction with CPT 86580. The appropriate diagnosis code for CPT 86580 is V74.1.

Generally, the nurse will administer the skin test and instruct the patient to return to the clinic for a reading a few days later. A nurse visit, CPT 99211 may be reported for the reading. The nurse must remember to document a proper nurse visit note (this is an E&M service)

• To be able to separate purchased vs. state supplied TST use the LU114 code for state supplied TST (report only) and the CPT code 86580 for purchased TST which can have a charge attached.

• If the client has private insurance only and a RN is the provider, you can use the 99211 E&M code. Other providers eligible to bill private insurance would use the appropriate E&M code for the level of service provided.

• When a client receives TB services (must be for a billable TB service) billed with an E&M code and is also seen by another health department provider on the same date of service for a separately identifiable medical condition, the health department may bill the appropriate E&M code, provided the diagnosis on the claim form indicates the separately identifiable medical condition and modifier 25 is deppended to the E & M code for the second visit.

TB treatment services

Performed by professional providers – office visits only The E/M codes 99201-99215 are for office visits only, and must be billed for professional providers such as physicians (or nursing staff under a physician’s supervision), Advanced Registered Nurse Practitioners (ARNPs), and Physician Assistants (PAs). Performed by professional providers – in client’s home, see home services.

Performed by nonprofessional providers – office visits and in client’s home Health departments billing for TB treatment services provided by nonprofessional providers in either the client’s home or in the office must bill using HCPCS code T1020 (personal care services). Do not bill the initial visit with a modifier. Follow-up visits must be billed using T1020 with modifier TS (follow-up services modifier). Use the appropriate ICD diagnosis code. See the agency’s Approved Diagnosis Codes by Program web page for Physician-Related Services/Health Care Professionals.

TB treatment services – performed by professional providers – in client’s home When billing for TB treatment services provided by professional providers in the client’s home, Health Departments may also bill CPT codes 99341 and 99347.

For TB treatment services performed by nonprofessional providers in client’s home, see TB treatment services for nonprofessional providers – office or client’s home

Targeted TB testing with interferon-gamma release assays

Targeted TB testing with interferon-gamma release assays may be considered medically necessary for clients age five and older for one of the following conditions:

• History of positive tuberculin skin test or previous treatment for TB disease
• History of vaccination with BCG (Bacille Calmette-Guerin)
• Recent immigrants (within 5 years) from countries that have a high prevalence of tuberculosis
• Residents and employees of high-risk congregate settings (homeless shelters, correctional facilities, substance abuse treatment facilities)
• Clients with an abnormal chest X-ray (CXR) consistent with old or active TB
• Clients undergoing evaluation or receiving TNF alpha antagonist treatment for rheumatoid arthritis, psoriatic arthritis, or inflammatory bowel disease
• Exposure less than two years before the evaluation

AND

• Client agrees to remain compliant with treatment for latent tuberculosis infection if found to have a positive test

The tuberculin skin test is the preferred method of testing for children under the age of 5.

CPT Code Short Description 86480 Tb test cell immun measure 86481 Tb ag response t-cell susp Providers must follow the agency’s expedited prior authorization (EPA) process to receive payment for targeted TB testing. See EPA #870001325 in EPA Criteria Coding List.

Procedure Code Short Description

85032 Manual cell count each
85046 Reticyte/hgb concentrate
85049 Automated platelet count
85378 Fibrin degrade semiquant
85380 Fibrin degradj d-dimer
85384 Fibrinogen activity
85396 Clotting assay whole blood
85610 Prothrombin time
85730 Thromboplastin time partial
86308 Heterophile antibody screen
86367 Stem cells total count
86403 Particle agglut antbdy scrn
86880 Coombs test
86900 Blood typing ABO
86901 Blood typing rh (d)
86920 Compatibility test spin
86921 Compatibility test incubate
86922 Compatibility test antiglob
86923 Compatibility test electric
86971 Rbc pretx incubatj w/enzymes
87205 Smear gram stain
87210 Smear wet mount saline/ink
87281 Pneumocystis carinii ag if
87327 Cryptococcus neoform ag eia
87400 Influenza a/b ag eia
89051 Body fluid cell count
86367 Stem cells total count
86923 Compatibility test electric
88720 Bilirubin total transcut
88740 Transcutaneous carboxyhb
88741 Transcutaneous methb

Medicaid Guide - TUBERCULOSIS TESTING

Medicaid covers tuberculosis (TB) testing according to the AAP periodicity schedule, and upon the recognition of high risk factors. Coverage for the TB test includes any return visit to read the results of the TB test. A risk assessment must be completed at each well child visit. Mantoux testing is the preferred testing method. For assistance in determining high risk and testing, providers may refer to the AAP Red Book: Report of the Committee on Infectious Diseases, or contact the MDHHS Division of Communicable Diseases and/or the Division of Immunization.

Medicaid Guidelines
TB nurse must bill TB services to Medicaid using T1002 and bill insurance using 99211 or T1002.

Sliding Fee Scale

1. A sliding fee scale can be attached to any program type, except STD and TB. Wherever a sliding fee scale is used, it must be consistently applied to all clients.
2. Not every program provided by LHDs must include a sliding fee scale (SFS). When a health department provides Adult Health Primary Care, Other services, Adult Dental services, it is their choice to apply a SFS (it is not required).
3. Health Department Dental Clinics are required to apply a SFS but it does not have to slide to zero.
4. Some DPH programs require that if their monies are used to provide a service, the fee for that service must slide to zero (e.g. Maternal Health, Family Planning, and Child Health).

Situations may exist where LHDs must bill services to Medicaid one way and private insurance (3rd party payers) a different way. Example: STD & TB - LHD may bill a T1002 to Medicaid and some private insurers. Some private insurers only accept 99211. Verify with each insurance carrier which codes they accept.

Laboratory services:

Medicaid will not reimburse separately for routine laboratory tests (Hemoglobin/Hematocrit and TB skin test) when performed during a Health Check early periodic screening visit. Other laboratory tests, including, but not limited to, blood lead screening, dyslipidemia screening, pregnancy testing, urinalysis, and sexually transmitted disease screening for sexually active youth, may be performed and billed when medically necessary. There must be documented symptoms or identified risks (based on history or physical exam) to bill for any additional labs (as part of a Periodic or Inter-periodic well child/preventive visit or as part of a sick/problem visit that may be provided on the same day as a preventive service). It must be supported with an appropriate ICD-10 code to explain why the service is being provided/requested, and the appropriate CPT code for the laboratory service must also be included.

TB nurse must bill TB services to Medicaid using T1002 and bill insurance using 99211 or T1002.

The following Physician or Advanced Practice Practitioners in a LHD setting are eligible to provide TB service:

* Physician (billed by E/M codes)
* Nurse Practitioner* (billed by E/M codes)
* Physician Assistants* (billed by E/M codes) Public Health Nurses* (billed by T1002 or reported by use of the appropriate LU code)
* Public health nurses (RNs) supervised by the public health nurse (RN) who is responsible for the TB Control Program and shall complete the Introduction to Tuberculosis Management course.
*Advanced Practice Practitioner

TB Disease or Contacts:

a. Per GS 130A-144 “the local health department shall provide, at no cost to the patient, the examination, and treatment for tuberculosis disease and infection...” As a result, TB services that deal with the examination and treatment of TB must be free or if billed to Medicaid or a third party payer the LHD must assure that the patient is not being billed for anything. This becomes problematic because most insurance companies have in their contract with the health department that they must collect co-pay from the insured patient. Medicaid does not require that a co-pay be collected due to this law. If you bill private insurance, then you would need to negotiate the copay issue with the insurance company.

b. The T1002 visit for TB clients is billed in units based on time recorded in client record by a Public Health (PH) Nurse under the guidance of a PH Nurse that has had the Introduction to TB course. The T1002 visits are for the monthly evaluation of clients on TB medication and not for DOT visits. (DOT is not a billable service, but DOT visits should be captured using LU121 or LU122). If your IT system does not accommodate the use of the LU Codes, please consult your vendor for further guidance. Time spent with eligible nurse seeing the client must be documented in the medical record. A good practice is to document time = units. Example: 30 minutes = 2 units. Remember: 1 unit = a full 15 minutes. Procedure code T1002 cannot be billed on the same day that a preventive medicine service is provided.

c. A maximum of 4 units per day may be billed per client. The time spent for each visit must be documented in the medical record. Time is defined as total time spent; for instance, 30 minutes’ time spent = 2 units. The documentation recording the TB service components provided should support the number of units billed.

d. Clients that are contacts to TB or are symptomatic cannot be charged for a TB skin test. Clients who need a TB skin test for reasons of employment or school may be charged if the health department uses purchased supply. (Reading the TB SKIN TEST is included as part of the total charge)

e. If the only service that a client comes in for is a skin test due to employment, school, etc., it should go under the TB program type. However, if the client comes in for another service like MH, CH, or FP and it is determined as a part of the history that they are at high risk for TB and need a skin test, then that TB SKIN TEST should go under the program that the client is in. The basic rule is that the TB SKIN TEST was then related to the program that brought the client in and is determined by the purpose of the visit.

f. To be able to separate purchased vs. state supplied TB SKIN TEST, use the LU114 code for state supplied TB SKIN TEST (report only) and the CPT code 86580 for purchased TB SKIN TEST, which can have a charge attached. If your vendor is unable to support the use of LU codes, you may need to work out a different mechanism for reporting state supplied TB SKIN TEST.

g. If the client has private insurance and an RN is providing monthly assessments, you can bill private insurance with the client’s permission using 99211 or T1002 provided the components to support the 99211 or T1002 are necessary and documented. Other Physician or Advanced Practice Practitioners eligible to bill private insurance would use the appropriate E/M code for the level of service, provided the components to support the E/M code are necessary and documented.

h. When a client receives a billable TB service (billed using an E/M code) and is also seen by the same health department Physician or Advanced Practice Practitioner on the same date of service for a separately identifiable medical condition, the health department may bill the appropriate E/M code, provided the diagnosis on the claim form indicates the separately identifiable medical condition and modifier 25 is appended to the E/M code that correlates to the primary reason for their visit to the health department. If the client is seen by a different health department Physician or Advanced Practice Practitioner on the same date of service …… no 25 modifiers is needed.

TB Skin Test (TST) and Interferon Gamma Release Assays (IGRA’s) for Employment, College or other non-mandated reasons

a. Clients who need a TST or IGRA for reasons of employment or school may be charged if the health department uses purchased supply. (Reading the TB skin test is included as part of the total charge.) It is preferable to use symptom and risk screening questionnaires in lieu of placing a skin test for low risk individuals and to place the skin test or obtain an Interferon Gamma Release Assay (IGRA) if the person responds yes to any of the questions. IGRA’s are preferred in this situation.

b. TST’s and IGRA’s can be provided as a flat fee service as long as the client does not qualify as “free” per TB program guidelines because the TB program does not have a required sliding fee scale.

c. If the only service that a client comes in for is a skin TST or IGRA due to employment, school, etc., it should go under the TB program type. However, if the client comes in for another service like MH, CH, or FP and it is determined as a part of the history that they are at high risk for TB and need a TST or IGRA, thenthat TST or IGRA should go under the program that the client is seen in. The basic rule is that the TST or IGRA was then related to the program that brought the client in and is determined by the purpose of the visit.

d. TB skin tests can be provided as a flat fee service as long as the client does not qualify as “free” per TB program guidelines because the TB program does not have a required sliding fee scale.

e. If the only service that a client comes in for is a skin test due to employment, school, etc., it should go under the TB program type. However, if the client comes in for another service like MH, CH, or FP and it is determined as a part of the history that they are at high risk for TB and need a skin test, then that TB skin test should go under the program that the client is seen in. The basic rule is that the TB skin test was then related to the program that brought the client in and is determined by the purpose of the visit.

Communicable Disease

1. EPI Program type is used for General Communicable Disease activities including Hepatitis A, Hepatitis B, food-borne outbreaks as well as other reportable disease investigations and follow-ups other than STD or TB. Clinical visits can be reported using the appropriate CPT Ccde, and there are LU codes that can be used to report activities that don’t fit into a CPT code.

2. EPI services cannot be charged to the client but if a clinical service is provided that is a billable service Medicaid may be charged. Other third party payers may be charged with permission from the client. For additional program guidance, please contact your Regional Communicable Disease Consultant or visit the program website at http://epi.publichealth.nc.gov/cd/lhds.html

CPT 81001, 81002, 81003 AND 81025 - urinalysis

CPT CODES and Description

81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy

81001 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy- Fee schedule amount $3-$4

81002 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy Fee schedule amount $3-$4

81003 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy Fee schedule amount $3-$4

81005 Urinalysis, qualitative or semi-quantitative, except immunoassays Fee schedule amount $3-$4

81007 Urinalysis, bacteriuria screen, by non-culture, commercial kit Fee schedule amount $3-$5

81015 Urinalysis, microscopic only Fee schedule amount $3-$5

81025 Urine pregnancy test, by visualcolor comparison methods Fee schedule amount $8-$11

81050 Volume measurement for timed collection, each Fee schedule amount $4-$5

Indications and Limitations of Coverage and/or Medical Necessity

Urinalysis is one of the most useful indicators of health and disease, and is especially helpful in the detection of renal or metabolic disorders. It aids in diagnosing and following the course of treatment in diseases of the kidney and urinary system and in detecting disorders in other parts of the body such as metabolic or endocrinologic abnormalities in which the kidneys function normally.

The components of a urinalysis include an evaluation of physical characteristics (color, odor, and opacity); determination of specific gravity and pH; detection and measurement of protein, glucose, and ketone bodies; and examination of sediment for blood cells, casts, and crystals. Some laboratories include screening for leukocyte esterase and nitrate and do not perform a microscopic examination unless one of the chemical screening (macroscopic) tests is abnormal or unless a specific request for microscopic examination is made.

Diagnostic laboratory methods include visual examination; reagent strip screening; refractometry for specific gravity; and microscopic inspection of centrifuged sediment.

Urinalysis can be performed either by automated instruments or the use of tablets, tapes or dipsticks. Dipsticks are chemically impregnated reagent (reactive) strips that allow for quick determination of pH, protein, glucose, ketones, bilirubin, hemoglobin, nitrate, leukocyte esterase, and urobilinogen. The tip of the dipstick is impregnated with chemicals that react with specific substances in the urine to produce colored end products. Color standards are provided against which the actual color can be compared. The reaction rates of the impregnated chemicals are standard for each dipstick, and color changes must be matched at the correct time after each stick is dipped into the urine specimen.

Normally, the color is straw to dark yellow, specific gravity 1.005-1.035, pH 4.5-8.0, normal urobilinogen, and negative for protein, glucose, ketones, bilirubin, hemoglobin, erythrocytes (RBCs), Nitrite (bacteria), and leukocytes (WBCs).

A urinalysis study will be considered medically reasonable and necessary for the following conditions:

- Clinical symptomatology which may indicate a urinary system condition such as urgency; frequency; dysuria; flank pain; suprapubic discomfort; hematuria; fever of unknown origin; chills; swelling in the periorbital, abdominal and pedal areas of the body; heavy foaming urine, etc.;

- Physical examination reveals distended bladder with associated symptoms listed above;

- Patients on medications that are nephrotoxic (e.g., aminoglycosides); or

- Evaluation of patient’s response to treatment, such as antibiotic therapy for a UTI.

Conditions in which a urinalysis may be medically necessary are not limited to the following: urinary tract infection, glomerulonephritis, kidney stone, interstitial nephritis, nephrotic syndrome, acute renal failure, polynephritis, diabetic neuropathy, polycystic kidney disease, hyperplasia of prostate, rheumatoid arthritis, and renoparenchymal hypertension.

Even though a patient has a condition stated above, it is not expected that a urinalysis be performed frequently for stable chronic symptoms that are associated with that disease.

Other Urine Tests

If the lab performs urinalysis by another method, you might use one of the following codes:

** 81005 — Urinalysis; qualitative or semiquantitative, except immunoassays

This code describes a test that is different from 81002 or 81003 because the lab uses a colorimetric analyzer rather than a dipstick, and because the test results may be semiquantitative. You also should distinguish this code from urinalysis by immunoassay (83518, Immunoassay for analyte other than infectious agent antibody or infections agent antigen; qualitative or semiquantitative, single step method [e.g., reagent strip]).

** 81007 — Urinalysis; bacteriuria screen, except by culture or dipstick

Report this code if the lab screens for bacteria in the urine using a method other than dipstick or culture. For dipstick use 81000 or 81002; for culture see 87086 and 87088 (Culture, bacterial … urine).

** 81015 — Urinalysis; microscopic only

Use this for stand-alone urine microscopy — if the lab performs other urine tests use the complete code such as 81000 or 81001.

Billing and Coding Guidelines and Tips

Note that the tests mentioned on the first page of the list attached to CR8212 (CPT codes: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test.

Note: Medicare contractors will not search files to either retract payment or retroactively pay claims based on the changes in CR8212, however, claims should be adjusted if you bring them to your contractor’s attention.

Use CLIA modifier: If the lab that performs the test operates under a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver, you should report most urinalysis tests with modifier QW (CLIA waived test). Exception: Because it is the simplest urine dipstick (manual, without microscopy), 81002 is one of the original CLIAwaived tests and does not require modifier QW.

Example: The physician-office lab performs urinalysis for ketones, protein, hemoglobin, and glucose using the Bayer Clinitek Status Urine Chemistry Analyzer.

Solution: Because the lab uses the automated analyzer for common constituents, report the service as 81003-QW.

Don’t combine 81015 with 81002 or 81003.

Pregnancy test: For a colorimetric urine pregnancy test, report 81025 (Urine pregnancy test, by visual color comparison methods).

Services billed to Medicare must be documented as billed and be medically necessary. Without documentation the service was performed, no payment can be made. Periodic self audits of your Medicare billing and documentation is recommended to avoid this type of error.

UnitedHealthcare follows ACOG coding guidelines and considers CPT laboratory codes 81000 and 81002 as included in the global antepartum or global OB service when submitted with an OB diagnosis code in an office setting.

The following services are included in the global obstetrical package related to both vaginal and Caesarean delivery and will not be reimbursed separately when performed by the OB provider.
• Pregnancy test (CPT codes 81025, 84702, 84703

As noted in the Provider Manual, EmblemHealth uses manifold types of commercially available claims review software to support the correct digest of proclaim that result in ingenuous, widely recognized and transparent payment policies.* One of these policies hasten CPT code 81002 and CPT code 81003 (Urinalysis, by dip stick or tablet test) when recital with an Evaluation and Management service (e.g., CPT codes 99201-99205, 99211-99215 and 99381-99397). CPT digest 81002 and 81003 will not be separately reimbursed unless Modifier 25 is annex to the E/M service indicating that a diagnostic, non-screening, urinalysis was transact.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

13 - Hospital Outpatient
14 - Hospital - Laboratory Services Provided to Non-patients
22 - Skilled Nursing - Inpatient (Medicare Part B only)
23 - Skilled Nursing - Outpatient
72 - Clinic - Hospital Based or Independent Renal Dialysis Center
85 - Critical Access Hospital

Documentation Requirements

Medical record documentation maintained by the ordering/referring physician/nonphysician practitioner must indicate the medical necessity for performing the test including:

- office/progress notes

- laboratory results

If the provider of the service is other than the ordering/referring physician/nonphysician practitioner, the provider of the service must maintain documentation of test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the studies. The physician/nonphysician practitioner must state the clinical indication/medical necessity for the study in his order for the test.

Drug confirmation tests are not eligible to be separately reported under any procedure code, unlisted codes or otherwise. See below for additional details.

* Specimen validity testing is not eligible to be separately billed under any procedure codes (e.g. 81000, 81001, 81002, 81003, 81005, 81099, 82570, 83986, or any other code). This is because for all codes in range 80305 – 80307 & G0480 – G0483, G0659, the code description indicates that this testing is included if it was performed.

* CPT codes 80150, 80162, 80163, 80165, 80171, and 80299 are expected to be used only when the patient is on a prescription of the drug in question.

o These codes should not be used to report urine drug testing for illicit use of these drugs. Use 80305 – 80307, G0480 – G0483, G0659 instead.

o For unlisted code 80299, a description must be provided on the claim describing the therapeutic drug which is being quantified. (CPT guidelines for unlisted code reporting)

* CPT code 80299 Quantitation of therapeutic drug, not elsewhere specified is considered included in 80305 – 80307, G0480 – G0483, and G0659 when submitted in combination with these codes

Services Included in the Global Obstetrical Package

Laboratory Tests

Oxford follows ACOG coding guidelines and considers CPT laboratory codes 81000 and 81002 as included in the global antepartum or global OB service when submitted with an OB diagnosis code in an office setting. Assistant Surgeon and Cesarean Sections

Only a non-global cesarean section delivery code (CPT codes 59514 or 59620) is a reimbursable service when submitted with an appropriate assistant surgeon modifier. Refer to the Assistant Surgeon policy for additional information regarding modifiers and reimbursement. Prolonged Physician Services Prolonged physician services for labor and delivery services are not separately reimbursable services. CPT codes for prolonged physician services (99354, 99355, 99356, 99357, 99358, 99359, 99415, and 99416) are add-on codes used in conjunction with the appropriate level E/M code. As described in ACOG coding guidelines, prolonged services are not reported for services involving indefinite periods of time such as labor and delivery management.

Independent Laboratory Billing:

* Billing Taxonomy Code 291U00000X billed with the following lab CPT Codes:

80047 80048 80051 80053 80061 80069 81000 81001 81002 81003 82040 82042 82043 82044 82150 82232 82310 82374 82435 82436 82565 82570 82575 83020 83021 83026 83615 83625 83735 84075 84078 84080 84100 84105 84132 84133 84134 84155 84156 84157 84160 84163 84165 84295 84300 84450 84460 84520 84525 84540 84545 84550 84560 85002 85004 85007 85008 85009 85013 85014 85018 85025 85027 85041 85044 85045 85046 85048 85049 85060 85610 85611 85730

Lab CPT codes list which can be performed by CLIA certified providers

Providers with a CLIA certificate may conduct the following laboratory tests in their offices:

Description Codes Description Codes

Urinalysis 81000- 81003

Crystal Identification 89060

Glucose 82947- 82948

ESR 85651, 85652

Prothrombin time 85610

BM Aspiration 85097

Tuberculosis Intra-Dermal Skin Test 86580

Platelet 85007

Urine Pregnancy Test 81025

Bilirubin Direct 82248

Tissue Exam (KOH) Prep 87220

Bilirubin Total 82247

Wet Mounts 87177, 87210

Hemoglobin Glycated 83036

FOBT (Hemocult) 82270

Blood Smear 85060

Strep Test Group A 87070, 87880

Molecular Cytogenetics Chromosomal 88273

CBC 85025- 85048

Molecular Cytogenetics Interphase 88274

BUN, Creatinine 82565

Special Stains Group I 88312

Potassium 84132

Special Stains Group II 88313

Hemoglobin 85018

Clinical Pathology Consultation Limited 80500

Semen Analysis 89300 - 89320

Clinical Pathology Consultation Comprehensive 80502

Sperm Evaluation 89329

Lead Testing 83655

Cervical Mucus Penetration Test 89330

Rapid Flu Test 87804

Clinical laboratory new waived tests

Note: This article was revised September 19, 2014, to reflect the revised change request (CR) 8805 issued September 17. The article was revised to correct the description in bullet point 7 under Background. Also the CR release date, transmittal number, and the Web address for accessing the CR are revised. All other information remains the same.

Provider types affected
This MLN Matters®article is intended for clinical diagnostic laboratory providers submitting clinical diagnostic laboratory claims to Medicare administrative contractors (MACs) for services to Medicare beneficiaries.

Provider action needed
The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be appropriately certified for each test performed. To ensure that Medicare & Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are currently edited at the CLIA certificate level.

The Current Procedural Terminology(CPT®) codes that the Centers for Medicare & Medicaid Services (CMS) consider to be laboratory tests under CLIA (and thus requiring certification) change each year. CR 8805 informs the MACs about the latest new CPT®codes that are subject to CLIA edits. Make sure your billing staffs are aware of these latest CLIA-related changes, and that you remain current with certification requirements.

Background
Listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under CLIA.

The CPT®codes for the following new tests must have the modifier QW (CLIA-waived test) to be recognized as a waived test. However, the tests mentioned on the first page of the list attached to CR 8805(i.e., CPT®codes:

81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test.

The CPT®code, effective date and description for the latest tests approved by the FDA as waived tests under CLIA are the following:

G0434QW, September 6, 2013, BTNX Inc. Rapid Response Multi-Drug Urine Test Cup;
G0434QW, September 6, 2013, BTNX Inc. Rapid Response Multi-Drug Urine Test Panel;
G0434QW, October 4, 2013, uVera Diagnostics, Inc. CR2 Multi-Drug Urine Test Cup;
G0434QW, October 4, 2013, uVera Diagnostics, Inc. CR3 Multi-Drug Urine Test Cup;
G0434QW, October 4, 2013, uVera Diagnostics, Inc. SMARTOX U3 Multi-Drug Urine Test Cup;
G0434QW, October 24, 2013, American Institute of Toxicology, Inc., AIT Laboratories Drug of Abuse Cup;

80061QW, 82962, 82465 QW, 83718 QW, 84478 QW, November 12, 2013, Jant Pharmacal Corp, LipidPlusProfessional Lipid Profile and Glucose Measuring System (LipidPlus Lipid Profile test strips);

G0434QW, December 4, 2013, Nobel Medical Inc. INSTA-SCREEN Multi-Drug Urine Test Cup;
G0434QW, December 5, 2013, Micro Distributing II, LTD One Step Multi-Drug Urine Test Panel;
G0434QW, February 11, 2014, Alfa Scientific Designs, Inc. Confidential Drug Test – Multi Drugs of Abuse Urine Test (OTC);
87880 QW, February 18, 2014, BD Veritor System for Rapid Detection of Group A Strep (direct from throat swab);
85018 QW, February 18, 2014, Clarity HbCheck Hemoglobin Testing System;
87077 QW, February 18, 2014, Jant Accutest Rapid Urease test (H. pylori detection);
G0434QW, March 13, 2014, UCP Biosciences, Inc. UCP Multi-Drug Test Key Cups;
83986 QW, March 18, 2014, RightBio Metrics, RightSpot Infant pH Indicator;
83986 QW, March 18, 2014, RightBio Metrics, RightSpot pH Detector;
83986 QW, March 18, 2014, RightBio Metrics, RightSpot pH Indicator;
85018 QW, March 21,2014, AimStrip Hb Hemoglobin (Hb) Testing System;
G0434 QW, April 11, 2014, PTox Drug Screen Cup {Cassette Dip Card format};
86308 QW, April 22, 2014, Polymedco Polystat Mono {whole blood};
82274 QW, G0328QW, April 22, 2014, Rapid Response(TM) FIT-Fecal Immunochemical Test;
84443 QW, May 16, 2014, Germaine Laboratories, Inc. AimStep Thyroid Screen {whole blood};
82055 QW, May 21, 2014, Express Diagnostics International, Incorporated Saliva Alcohol Test;

83037 QW, May 22, 2014, BIO-RAD in2it (II) System Analyzer Prescription Home Use; and
87880 QW, May 23, 2014, Accustrip Strep A {Specimen type (Throat Swab)}.

You should be aware that your MAC will not search their files, to either retract payment or retroactively pay claims; however, they should adjust such claims that you bring to their attention.

payment for CLIA waived CPT codes

CLIA Waived Tests for Manufacturers

Clinical Laboratory Improvement Amendment of 1988 (CLIA). The CLIA-waived status allows a broad base of physicians to perform a test at the point-of-care setting.

CPT CODE	MEDICARE FEE CAP	TEST NAME (SELECTED PRODUCTS/MANUFACTURERS)
82055QW	$15.10	Alcohol Saliva Test (STC Diagnostics, QED Diagnostics)
82120QW	$5.25	Amines and pH (Advance Amines and pH test, Quidel, BV Blue, Sekisui Diagnostics)
83986QW	$5.00	Amines and pH (Advance Amines and pH test, Quidel, BV Blue, Sekisui Diagnostics)
85576QW	$30.01	Aspirin resistance test (VerifyNow Accumetrics)
87905QW	$17.20	Bacterial Vaginosis (Sekisui Diagnostics)
83518QW	$11.85	Bladder Cancer Antigen (BTA Stat Test Bion Diagnostics)
83880QW	$47.43	BNP test (Triage Meter, Biosite Corp)
87324	$16.88	C. difficille (Sekisui Diagnostics)
Varies	Varies	Chemistry Tests: Albumin, Alkaline Phosphatase, Amylase, GGT, Total Bilirubin, Total Protein (Abaxis Piccollo)
82465QW	$6.08	Cholesterol (Chemtrak, J & J, Roche, Actimed Labs, Lifestream Technologies)
82044QW	$6.44	Dipstick Albumin (Chemstrip Micral Roche Corp, Immunodip, DCL, Sekisui Diagnostics)
81002	$3.57	Dipstick/Tablet Urinalysis
81002	$3.57	Dipstick Urinalysis
82570QW	$7.23	Creatinine (Bayer Multistix Pro 11, 10LS, 7G)
81003QW 82570QW	$3.14 $7.23	Dipstick Urine Analyzer (Clinitek 50 Bayer Corp.; Urisys Roche Corp.)+ Creatinine (Bayer Status Analyzer)
80101QW	$19.24	Drugs of Abuse tests
82272	$4.54	FOB, Diagnostic (Hemoccult Beckman Coulter, Seroccult Propper)
82270	$4.54	FOB, Screening
G0394	$4.54	FOB, single test for colorectal neoplasm
82274QW or G0328	$22.22	FOB, Immunoassay (InSure Enterix, FOB Alfa Scientific, Hemoccult ICT Beckman Coulter, Instant Technologies, Immunostics)
83001QW	$25.97	FSH (Biotechnostics, Menocheck Pro FSH Menopause Test)
82273QW	$4.54	Gastric Occult Blood (Beckman Coulter)
82962	$3.27	Glucose Meters
82951QW	$17.99	Glucose Tolerance Test, 3 Specimens
82947QW	$5.48	Glucose (HemoCue Glucose 201 Analyzer)
83036QW	$13.56	Hemoglobin A1c (Axis-Shield Afinion, Bayer DCA 2000)
83037QW	$21.06	Hemoglobin A1c, approved for home use (Cholestech, Metrika, BioRad, Provalis)
85014QW	$3.31	Hematocrit (StatSpin)
85018QW	$3.31	Hemoglobin (Hemocue)
86318QW	$18.22	H. pylori test whole blood (Quidel, BD, Accutest, Instant Technologies, Sekisui Diagnostics)
87338QW	$20.10	H. pylori test, stool (Meridian Bioscience, Immunocard)
86703QW	$19.17	HIV Rapid Test (OraSure)
87804QW	$16.88	Influenza Rapid Test Kits (Quidel, Binax, Sekisui Diagnostics)
83655QW	$16.91	LeadCare II Blood Lead Test System (ESA Biosciences, Chelmsford, MA)
80061QW	$18.72	Lipid Panel (Cholestech, Abaxis, Cardiocheck) (Cholest, HDL, Triglycerides)
84460QW	$7.40	ALT (SGPT)
84450QW	$7.40	AST (SGOT)
83721QW	$13.33	LDL (Polymer Technology; Cardiocheck PA)
86618QW	$23.80	Lyme Disease Rapid Test Kit (Inverness)
82043QW	$8.09	Microalbumin, Urine Quantitative (Hemocue)
83518QW	$11.85	Microalbumin Immunoassay (ICON Beckman Coulter)
86308QW	$7.28	Mononucleosis Test Kits (Quidel, Inverness, Sekisui Diagnostics)
80101QW	$19.24	Nicotine Test (NicCheck, Dynagen)
84830	$14.02	Ovulation Test Kits (Instant Technologies)
81025	$8.90	Pregnancy Test Kits Urine, Qualitative (Beckman Coulter, Sekisui Diagnostics, Quidel, Inverness)
84703QW	$10.49	Pregnancy Test Urine Instrument (Clinitek Bayer Corp)
85610QW	$5.49	Prothrombin Time (Protime ITC Corp, CoaguChek Roche, Hemosense)
87807QW	$16.76	RSV Rapid Test Kit (Binax, Integrated Biotechnology)
85651	$4.96	Sedimentation Rate, Non-Automated
87880QW	$16.88	Strep Rapid Test Kits (Beckman Coulter, Sekisui Diagnostics, Quidel, BD, Inverness, Sekisui Diagnostics, etc.)
87808QW	$16.88	Trichomonas Rapid Test Kit (Sekisui Diagnostics)
84443QW	$23.47	TSH, qualitative (Thyrotech)
81007QW	$3.59	Urinary Tract Infections (Uriscreen Diatech Diagnostics)

This list omits certain waived tests that are typically not performed in physician office settings.

Indications for usage of CPT code 83880

Congestive Heart Failure (CHF) is a complex clinical syndrome characterized by dysfunction of the left, right, or both ventricles, which results in the impairment of the heart’s ability to circulate blood at the rate sufficient to maintain the metabolic needs of the peripheral tissues and various organs. B-type natriuretic peptide (BNP) is synthesized, stored, and released primarily by the ventricular myocardium in response to volume expansion and pressure overload, which are hemodynamic parameters in CHF. Used in conjunction with other clinical information, serum BNP concentrations parallel dyspnea in heart failure suggesting its usefulness as a neurohormonal index of progressive heart failure. Serum BNP, for the purposes of coverage, is considered a ‘point-of-service test (performed and immediately used in the disposition of patient care).

Serum BNP, when used in conjunction with other clinical information, will be considered reasonable and necessary for the following:

Establishing the diagnosis of CHF in acutely ill patients presenting with dyspnea.

Predicting the long term risk of cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after an acute coronary event. Since this situation is an inpatient service, it is not addressed in this LCD.

Limitations

Serum BNP will be considered noncovered in the following:

Monitoring the efficiency of treatment for CHF

Tailoring the therapy for heart failure

Since BNP is a point of service test, the primary outpatient site of service expected to perform a serum BNP is the emergency room or a physician’s office.

Medicare Payment, Reimbursement, CPT code, ICD, Denial Guidelines

Medicare Guideline posts