19-704 Clarification Regarding Physicians Office Lab Testing Policy Change
Date: 09/27/19
Clarification Regarding Physician’s Office Lab Testing Policy Change
Applies to members enrolled with a managed care plan but not assigned to a delegated IPA
As a clarification to provider update 19-604, Reminder: Physician’s Office Lab Testing Policy Change, please be advised that the change applies to members enrolled with a managed care plan but not assigned to a delegated independent practice association (IPA). Provider update 19-604 had advised it applied to Medi-Cal fee-for-service (FFS) members.
Effective July 5, 2019, California Health & Wellness Plan (CHWP), for its members enrolled with a managed care plan but not assigned to a delegated IPA, no longer reimburses providers for laboratory (lab) tests performed in a physician’s office – place of service (POS) code 11 – unless deemed medically necessary and listed in policy CC.PP.055, Physician’s Office Lab Testing, as described in provider update 19-343, Avoid Unnecessary Claims Denials and Processing Delays.
The policy leverages the specialization of independent labs and ensures higher quality tests at lower costs. The list of codes below has been clinically approved by the plan’s medical management to ensure patient care is not compromised due to the enactment of the policy. Prior authorization may be required. CHWP prior authorization requirements can be accessed online on the CHWP website at www.CAHealthWellness.com.
View policies simply
CHWP clinical and payment policies can be accessed online on the CHWP website at www.CAHealthWellness.com under For Providers > Provider Resources > Clinical & Payment Policies.
Use contracted labs like Quest Diagnostics® and LabCorp® to avoid claims delays
Physicians in need of lab tests for the care of CHWP members should send all requests to Quest Diagnostics, LabCorp or other contracted independent lab. To find a Quest Diagnostics center near you or request a pickup, visit www.QuestDiagnostics.com or call Quest Diagnostics toll free at 1-866-MYQUEST (1-866-697-8378). To find a LabCorp center near you or request a pickup, visit www.LabCorp.com or call 1-800-244-9698.
Providers can also find Quest, LabCorp or other contracted lab locations on the CHWP website at www.CAHealthWellness.com by selecting For Members > Find a Provider.
Use correct codes to help you bill services
Codes for services that require a short turnaround time (STAT) due to medical necessity, or codes that are deemed to fall under sensitive services, will be reimbursed to physicians after services have been rendered. All other tests not on the list will be denied and should be sent to Quest Diagnostics, LabCorp or other contracted independent lab.
19-704/OTH034882EH00 (9/19)
To ensure higher quality lab tests are performed in the correct setting, in-office lab testing will only be allowed for the CPT and HCPCS codes listed in the STAT lab code list included in policy CC.PP.055.
These are tests that are needed immediately in order to manage medical emergencies or urgent conditions. To this end, specific clinical lab tests have been designated as appropriate to be performed in the office setting.
Reimbursement for in-office lab procedures is limited to those codes listed in the STAT lab procedure code list (see the Coding and Modifier Information section in the policy). Lab procedures not included on the STAT lab list should be referred to an independent, contracted lab provider.
Sensitive services testing can continue to be performed in the physician’s office.
The table below lists codes to be used for reimbursable STAT lab services and a description of the procedure for respective codes.
List of codes for reimbursable STAT lab services
Code | Description |
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 |
80307 | Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service |
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 |
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 |
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 |
81005 | Urinalysis; qualitative or semiquantitative, except immunoassays |
81015 | Urinalysis; microscopic only |
81025 | Urine pregnancy test, by visual color comparison methods |
82043 | Albumin; urine, microalbumin, quantitative |
82044 | Albumin; urine, microalbumin, semiquantitative (e.g., reagent strip assay) |
82247 | Bilirubin; total |
List of codes for reimbursable STAT lab services, continued
Code | Description |
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 3 cards or single triple card for consecutive collection) |
82271 | Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; other sources |
82272 | Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening |
82465 | Cholesterol, serum or whole blood, total |
82565 | Creatinine; blood |
82731 | Fetal fibronectin, cervicovaginal secretions, semi-quantitative |
82947 | Glucose; quantitative, blood (except reagent strip) |
82948 | Glucose; blood, reagent strip |
82950 | Glucose; post glucose dose (includes glucose) |
82951 | Glucose; tolerance test (GTT), 3 specimens (includes glucose) |
82952 | Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) |
82962 | Glucose, blood by glucose monitoring device(s) cleared by the U. S. Food and Drug Administration (FDA) specifically for home use |
83036 | Hemoglobin; glycosylated (A1C) |
83655 | Lead |
83986 | pH; body fluid, not otherwise specified |
84132 | Potassium; serum, plasma or whole blood |
84703 | Gonadotropin, chorionic (hCG); qualitative |
85013 | Blood count; spun microhematocrit |
85014 | Blood count; hematocrit (Hct) |
85018 | Blood count; hemoglobin (Hgb) |
85025 | Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count |
85027 | Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count |
85049 | Blood count; platelet, automated |
85610 | Prothrombin time |
List of codes for reimbursable STAT lab services, continued
Code | Description |
85651 | Sedimentation rate, erythrocyte; non-automated |
86308 | Heterophile antibodies; screening |
86580 | Skin test; tuberculosis, intradermal |
86756 | Antibody; respiratory syncytial virus |
87070 | Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates |
87172 | Pinworm exam (e.g., cellophane tape prep |
87205 | Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types |
87210 | Smear, primary source with interpretation; wet mount for infectious agents (e.g., saline, India ink, KOH preps) |
87220 | Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (e.g., scabies) |
87270 | Infectious agent detection, by immunofluorescent technique, chlamydia trachomatis |
87490 | Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique |
87491 | Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique |
87492 | Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification |
87802 | Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group B |
87803 | Infectious agent antigen detection by immunoassay with direct optical observation; Clostridium difficile toxin A |
87804 | Infectious agent antigen detection by immunoassay with direct optical observation; Influenza |
87807 |
Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus |
87808 | Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis |
87880 | Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A |
87905 |
Infectious agent enzymatic activity other than virus (e.g., sialidase activity in vaginal fluid) |
List of codes for reimbursable STAT lab services, continued
Code | Description |
G0480 | Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed |
G0481 | Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed |
G0482 | Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed |
G0483 |
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed |
G0659 | Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes |
List of codes for reimbursable STAT lab services, continued
Code | Description |
Q0111 | Wet mounts, including preparations of vaginal, cervical or skin specimens |
Q0112 | All potassium hydroxide (KOH) preparations |
Additional information
Providers are encouraged to access CHWP’s provider portal online at www.CAHealthWellness.com for real-time information, including eligibility verification, claims status, prior authorization requirements or status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 1-877-658-0305.
Provider Update
|
Summary Update: Clarification Regarding Physician’s Office Lab Testing Policy Change
Applies to members enrolled with a managed care plan but not assigned to a delegated IPA
As a clarification to provider update 19-604, Reminder: Physician’s Office Lab Testing Policy Change, please be advised that the change applies to members enrolled with a managed care plan but not assigned to a delegated independent practice association (IPA). Provider update 19-604 had advised it applied to Medi-Cal fee-for-service (FFS) members.
Effective July 5, 2019, California Health & Wellness Plan (CHWP), for its members enrolled with a managed care plan but not assigned to a delegated IPA, no longer reimburses providers for laboratory (lab) tests performed in a physician’s office – place of service (POS) code 11 – unless deemed medically necessary and listed in policy CC.PP.055, Physician’s Office Lab Testing, as described in provider update 19-343, Avoid Unnecessary Claims Denials and Processing Delays.
The policy leverages the specialization of independent labs and ensures higher quality tests at lower costs. The list of codes has been clinically approved by the plan’s medical management to ensure patient care is not compromised due to the enactment of the policy. Prior authorization may be required. CHWP prior authorization requirements can be accessed online on the CHWP website at www.CAHealthWellness.com.
Comprehensive information is available in the complete update, 19-704, Clarification regarding Physician’s Office Lab Testing Policy Change. A copy of the complete update is available on the CHWP provider website at www.CAHealthWellness.com under For Providers > Provider News; search for provider update 19-704.
View policies simply
CHWP clinical and payment policies can be accessed online on the CHWP website at www.CAHealthWellness.com under For Providers > Provider Resources > Clinical & Payment Policies.
Use contracted labs like Quest Diagnostics® and LabCorp® to avoid claims delays
Physicians in need of lab tests for the care of CHWP members should send all requests to Quest Diagnostics, LabCorp or other contracted independent lab. To find a Quest Diagnostics center near you or request a pickup, visit www.QuestDiagnostics.com or call Quest Diagnostics toll free at 1-866-MYQUEST (1-866-697-8378). To find a LabCorp center near you or request a pickup, visit www.LabCorp.com or call 1-800-244-9698.
Providers can also find Quest, LabCorp or other contracted lab locations on the CHWP website at www.CAHealthWellness.com by selecting For Members > Find a Provider.
19-704sum/OTH034882EH00 (9/19)
Provider Update
Use correct codes to help you bill services
Codes for services that require a short turnaround time (STAT) due to medical necessity, or codes that are deemed to fall under sensitive services, will be reimbursed to physicians after services have been rendered. All other tests not on the list will be denied and should be sent to Quest Diagnostics, LabCorp or other contracted independent lab.
To ensure higher quality lab tests are performed in the correct setting, in-office lab testing will only be allowed for the CPT and HCPCS codes listed in the STAT lab code list included in policy CC.PP.055.
These are tests that are needed immediately in order to manage medical emergencies or urgent conditions. To this end, specific clinical lab tests have been designated as appropriate to be performed in the office setting.
Reimbursement for in-office lab procedures is limited to those codes listed in the STAT lab procedure code list (see the Coding and Modifier Information section in the policy). Lab procedures not included on the STAT lab list should be referred to an independent, contracted lab provider.
Sensitive services testing can continue to be performed in the physician’s office.
Additional information
Providers are encouraged to access CHWP’s provider portal online at www.CAHealthWellness.com for real-time information, including eligibility verification, claims status, prior authorization requirements or status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 1-877-658-0305.