New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 9 - HEALTH CARE FINANCING ADMINISTRATION (HCFA) COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:54-9.9 - Pathology and Laboratory HCPCS Codes-Qualifiers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Qualifiers for pathology and laboratory services are summarized below:
1. Chemistry Automated, Multichannel Tests
Applies to CPT Codes: 80002, 80003, 80004, 80005, 80006, 80007, 80008, 80009, 80010, 80011, 80012, 80016, 80018, and 80019. The following list contains those tests which can be and are frequently performed as groups and combinations (profiles) on automated multichannel equipment: Apply this methodology to the above CPT Codes. For reporting one test, regardless of method of testing, use appropriate single test code number. For any combination of tests among those listed below use the appropriate number 80002-80019. Groups of the tests listed here are distinguished from multiple tests performed individually for immediate or 'stat' reporting. Laboratory chemistry tests performed on your automated equipment in addition to laboratory chemistry tests listed must be billed as 80002-80019 as part of the automated multichannel test listing.
Acid-Phosphatase
Creatinine
Albumin
Gamma Glutamyl Transpeptidase
Alkaline Phosphatase
(GGTP)
(ALT, SGPT) Aspartate
Glucose (Sugar)
Aminotransferase
Iron
(AST, SGOT) Aspartate
Iron Binding Capacity
Aminotransferase
Lactic Dehydrogenase (LD)
Amylase
Lipoprotein (HDL Cholesterol)
Bilirubin, Total
Magnesium
Bilirubin, Direct
Phosphorus
Blood Urea Nitrogen (BUN)
Potassium (K)
Calcium
Protein, Total
Carbon Dioxide (C02)
Sodium (NA)
Clorides (C1)
Triglycerides
Cholesterol
Uric Acid
Creatine Kinase (CK, CPK)
NOTE 1: If any two of the following HCPCS procedure codes are performed on the same day by automated equipment and the total reimbursement of the two chemistry tests would have exceeded $ 5.00, the maximum reimbursement will not be more than $ 5.00: 82040, 82150, 82250, 82251, 82310, 82374, 82435, 82465, 82550, 82565, 82947, 82977, 83540, 83550, 83615, 83718, 83735, 84060, 84075, 84100, 84132, 84155, 84295, 84450, 84460, 84478, 84520, 84550.
NOTE 2: The following calculations and ratios are not eligible for separate or additional reimbursement. Mathematical calculations listed below are not reimbursable.
A/G Ratio
Globulin
BUN/Creatinine Ratio
FTI (T7)
Free Calcium
Free Thyroxine
NOTE 3: Any additional automated multichannel chemistry tests performed on same date as Codes 80002, 80003, 80004, 80005, 80006, 80007, 80008, 80009, 80010, 80011, 80012, 80016, 80018, and 80019 will not be reimbursed at the current allowable fee for each added test when performed on automated multichannel equipment.
NOTE 4: Code (W8200)--Glucose (separate tube, gray top) performed on the same date as the following chemistry profiles 80002, 80003, 80004, 80005, 80006, 80007, 80008, 80009, 80010, 80011, 80012, 80016, 80018 and 80019 will be paid an additional $ 2.00.
2. Codes 80050, 80055, 80058, 80059, 80061, 80072, 80090, 80091, 80092.--The panels listed must include the laboratory tests assigned by the CPT-4 as the components of the panel. The tests listed with each of the panels identify the defined components of that panel. If any three laboratory tests included in the panel are billed a la carte, the tests must be billed as the panel. The laboratory provider may not charge Medicaid more than the lowest charge level offered to another provider. The lowest charges for the laboratory test comprising the panel must aggregate as equivalent to or greater than the listed panel fee.
NOTE 1: Code 80091--Thyroid panel
Reimbursement not eligible for 84439 when billed in conjunction with 80091 on same day.
NOTE 2: Code 80092--Thyroid panel with TSH
Code 84443--TSH will not be paid a separate reimbursement when performed in conjunction with 80091 or 80092.
3. Codes 82487, 82488, and 82489--Chromatography--must list substance (compound) tested for in block 34 (REMARKS) of the claim form.
4. Code 82728--Ferritin
When the procedure for ferritin is performed in combination with Vitamin B12 or Folate or any of the chemistry analytes listed on codes 80002-80019, the maximum reimbursable fee for code 82728 is $ 5.00.
5. Code 84081--Phosphatidylglycerol--test done on newborn or amniotic fluid to determine fetal lung maturity.
6. Code 84202--Protoporphyrin, RBC; quantitative--Utilize only for testing of anemia. Utilize code 84203--Protoporphyrin, RBC; screen when testing for anemia. Code 84203 will not be reimbursed when billed in conjunction with code 83655--Blood lead determination (quantitative).
7. Code 84620--Xylose absorption tests, blood and/or urine (D-xylose tolerance test), includes serum & urine levels, up to 5 hourly specimens.
8. Codes 85023 and 85025--Hematology
NOTE: For purpose of reimbursement based on this schedule, a complete blood count (CBC) includes a hematocrit, hemoglobin determination, RBC count, RBC indices, WBC count and differential WBC count (see codes 85021 and 85022), for a platelet count with a CBC (see codes 85023-85025).
Hematology codes 85014, 85018, 85041 and 85048 will not be reimbursed in conjunction with codes for blood count with hemogram (85021, 85022, 85023, 85024, 85025, and 85027).
The code for manual differential WBC count (85007) will not be reimbursed in conjunction with codes 85021, 85022, 85023, 85024, 85025, and 85027.
Codes for platelet count (85590 and 85595) will not be reimbursed in conjunction with codes 85023-85027.
Code 85044 may be reimbursed in conjunction with codes 85023 and 85025, when a complete hemogram is ordered.
9. Codes 87040, 87045, 87060, 87070, 87184--Cultures
NOTE: These codes may only be billed when a pathogenic microorganism is reported. A culture that indicates no growth or normal flora must be billed as a presumptive culture, 87081 or 87082.
10. Code 88155--pap smear
NOTE: Obtaining specimen is not a separate eligible service.
11. Code 88348 and 89349--Electron microscopy; diagnostic and scanning are not reimbursable when used as a research tool.
NOTE: For reimbursement purposes, Medicaid will pay for the above diagnostic scanning procedure when it pertains to x-ray microanalysis for identification of asbestos particles and heavy metals, i.e.; gold, mercury, etc. and also when examining tissue specimens in occasional cases of malabsorption.
12. Code 89360--Sweat (without iontophoresis) test
NOTE: Reimbursement not eligible for qualitative tests. For reimbursement purposes, 84295 will not be reimbursed at any additional charge. Do not bill 84295 in conjunction 89360.
13. Code 36415--Utilize this code only for finger/heel/ear stick for collection of specimen(s). This service is reimbursable in the physician office laboratory (POL) when the specimen is not referred out to an independent clinical laboratory for testing. Finger/heel/ear stick is not reimbursable when billed by the independent clinical laboratory.
14. Code G0001--This service is reimbursable in the physician office laboratory (POL) when the specimen is not referred out to an independent clinical laboratory for testing. Venipuncture is not reimbursable when billed by the independent clinical laboratory. It is considered all inclusive as part of the laboratory test.
15. Code W8200--This code is reimbursable when submitted on same claim, and performed on same date as chemistry profiles.
16. Code W8900--This code may be used only once per trip regardless of the number of beneficiaries seen and requires a distance in excess of 20 miles per round trip.