Effective June 1, 2018

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Franklin Butler
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EMPIRE PHYSICIAN OFFICE LAB (POL) LIST Approved Laboratory Tests for Physician Offices Reimbursement is only available if the benefit is covered under the member's contract.

1 EMPIRE PHYSICIAN OFFICE LAB (POL) LIST Approved Laboratory Tests for Physician Offices Reimbursement is only available if the benefit is covered under the member's contract. Medical Policy edits will apply. Services provided by Empire Health Choice HMO, Inc. and/or Empire Health Choice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Effective June 1, 2018 SVC CODE DESCRIPTION FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE FINE NEEDLE ASPIRATION; WITH IMAGING GUIDANCE BONE MARROW; ASPIRATION ONLY BONE MARROW BIOPSY, NEEDLE OR TROCAR BASIC METABOLIC PANEL (CALCIUM, IONIZED) BASIC METABOLIC PANEL COMPREHENSIVE METABOLIC PANEL CLINICAL PATHOLOGY CONSULTATION; LIMITED, WITHOUT REVIEW OF PATIENT'S HISTORY AND MEDICAL RECORDS CLINICAL PATHOLOGY CONSULTATION; COMPREHENSIVE, FOR A COMPLEX DIAGNOSTIC PROBLEM, WITH REVIEW OF PATIENT'S HISTORY AND MEDICAL RECORDS URINALYSIS, BY DIPSTICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY URINALYSIS BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; WITHOUT MICROSCOPY, NON-AUTOMATED URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISONMETHODS BILIRUBIN; TOTAL BILIRUBIN; DIRECT BLOOD, OCCULT BY PEROXIDASE ACTIVITY (EG, GUAIAC) QUALITATIVE; FECES, SIMULTANEOUS DETERMINATIONS BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING CREATININE; BLOOD ESTRADIOL FETAL FIBRONECTIN, CERVICOVAGINAL SECRETIONS, SEMI-QUANTITATIVE GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO2 (INCLUDING CALCULATED O SATURATION); GASES, BLOOD, ANY COMBINATION OF PH, PCO2, CO2, HC02 (INCLUDING CALCULATED 02 SATURATION); WITH 02 SATURATION, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIMETRY June 2018 Services provided by Empire Health Choice HMO, Inc. and/or Empire Health Choice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Page 1 of 5

2 82948 GLUCOSE; BLOOD, REAGENT STRIP GONADOTROPIN; LUTEINIZING HORMONE (LH) HELICOBACTER PYLORI ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE HELICOBACTER PYLORI; DRUG ADMINISTRATION AND SAMPLE COLLECTION HEMOGLOBIN; GLYCATED LEAD MICROFLUIDIC ANALYSIS UTILIZING AN INTEGRATED COLLECTION AND ANALYSIS DEVICE, TEAR OSMOLARITY PH; BODY FLUID, NOT OTHERWISE SPECIFIED PROGESTERONE UREA NITROGEN; QUANTITATIVE BLEEDING TIME BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT BOLLD SMEAR, MICROSCOPE EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT BLOOD COUNT; SPUN MICROHEMATOCRIT BLOOD COUNT; HEMATOCRIT (HCT) BLOOD COUNT: HEMOGLOBIN (HGB) BLOOD COUNT; COMPLETE (CBC) AUTOMATED (HGB, HCT, RBC,WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT BLOOD COUNT; COMPLETE (CBC) AUTOMATED (HGH, HCT, RBC, WBC AND PLATELET COUNT) BLOOD COUNT: MANUAL CELL COUNT (ERYTHROCYTE, LEUKOCYTE, PLATELET), EACH BLOOD COUNT; RETICULOCYTE, MANUAL BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT BONE MARROW, SMEAR INTERPRETATION PLATELET; AGGREGATION (IN VITRO), ANY AGENT PROTHROMBIN TIME SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED HETEROPHILE ANTIBODIES; SCREENING PARTICLE AGGLUTINATION; SCREEN, EACH ANTIBODY SKIN TEST, CANDIDA SKIN TEST; UNLISTED ANTIGEN, EACH SKIN TEST; HISTOPLASMOSIS SLIN TEST; TUBERCULOSIS, INTRADERMAL CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY SMEAR, PRIMARY SOURCE, WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI OR CELL TYPES SMEAR, PRIMARY SOURCE, WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS) TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES) Page 2 of 5

3 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMI QUANTITATIVE, MULTIPLE STEP METHOD; STREPTOCOCCUS, GROUP A HUMAN PAPILLOMAVIRUS (HPV), HIGH RISK TYPES (EG, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; INFLUENZA INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; ADENOVIRUS INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; STREPTOCOCCUS, GROUP A CYTOPATHOLOGY, CERVICAL OR VAGINAL, (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER MANUAL SUPERVISION CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE CYTOHISTOLOGIC STUDY TO DETERMINE ADEQUACY OF SPECIMEN(S) CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; INTERPRETATION AND REPORT CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE CYTOHISTOLOGIC STUDY TO DETERMINE ADEQUACY FOR DIAGNOSIS, EACH SEPARATE ADDITIONAL EVALUATION EPISODE, SAME SITE LEVEL I SURGICAL PATHOLOGY, GROSS EXAMINATION ONLY LEVEL II SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION OF PRESUMPTIVELY NORMAL TISSUE(S); FOR IDENTIFICATION AND RECORD PURPOSES LEVEL III SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION OF PRESUMPTIVELT ABNORMAL TISSUE(S); UNCOMPLICATED SPECIMEN LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION LEVEL V - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION LEVEL IV SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION OF PRESUMPTIVELY ABNORMAL TISSUE(S); COMPLEX DIAGNOSTIC PROBLEM WITH OR WITHOUT EXTENSIVE DISSECTION DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR SURGICAL PATHOLOGY EXAMINATION) SPECIAL STAINS; (LIST SEPARATELY IN ADDITION TO CODE FOR SURGICAL PATHOLOGY EXAMINATION) GROUP 1 FOR MICROORGANISM (GRIDLEY, ACID FAST, METHENAMINE SILVER), EACH SPECIAL STAINS; GROUP 11, (EG, IRON, TRICHOME), EXCEPT IMMUNOCYTOCHEMISTRY AND IMMUNOPEROXIDASE STAINS, EACH SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR SURGICAL PATHOLOGY EXAMINATION) HISTOCHEMICAL STAINING WITH FROZEN SECTION(S) DETERMINATIVE HISTOCHEMISTRY OR CYTOCHEMISTRY TO IDENTIFY ENZYME CONSTITUENTS, EACH CONSULTATION AND REPORT ON REFERRED SLIDES PREPARED ELSEWHERE CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPARATION OF SLIDES CONSULTATION, COMPREHENSIVE, WITH REVIEW OF RECORDS AND SPECIMENS, WITH REPORT ON REFERRED MATERIAL PATHOLOGY CONSULTATION DURING SURGERY Page 3 of 5

4 PATHOLOGY CONSULTATION DURING SURGERY; FIRST TISSUE BLOCK, WITH FROZEN SECTION(S), SINGLE SPECIMEN PATHOLOGY CONSULTATION DURING SURGERY; EACH ADDITIONAL TISSUE BLOCK WITH FROZEN SECTION(S) IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, PER SPECIMEN; EACH ADDITIONAL SINGLE ANTIBODY STAIN PROCEDURE. IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, PER SPECIMEN; INITIAL SINGLE ANTIBODY STAIN PROCEDURE IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; DIRECT METHOD IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; INDIRECT METHOD ELECTRON MICROSCOPY; DIAGNOSTIC ELECTRON MICROSCOPY; SCANNING MORPHOMETRIC ANALYSIS; SKELETAL MUSCLE MORPHOMETRIC ANALYSIS; NERVE MORPHOMETRIC ANALYSIS; TUMOR NERVE TEASING PREPARATIONS TISSUE IN SITU HYBRIDIZATION, INTERPRETATION AND REPORT PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION AND REPORT; PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION; IMMUNOLOGICAL PROBE FOR BAND IDENTIFICATION, EACH CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, ANY BODY FLUID (EXCEPT URINE) SWEAT COLLECTION BY IONTOPHORESIS CULTURE AND FERTILIZATION OF OOCYTE(S); CULTURE AND FERTILIZATION OF OOCYTE(S): WITH CO-CULTURE OF EMBRYOS ASSISTED EMBRYO HATCHING, MICROTECHNIQUES (ANY METHOD) OOCYTE IDENTIFICATION FROM FOLLICULAR FLUID PREPARATION OF EMBRYO FOR TRANSFER (ANY METHOD) SPERM IDENTIFICATION FROM ASPIRATION (OTHER THAN SEMINAL FLUID) SPERM ISOLATION; SIMPLE PREP (EG, SPERM WASH AND SWIM-UP) FOR INSEMINATION OR DIAGNOSIS WITH SEMEN ANALYSIS SPERM ISOLATION; COMPLEX PREP (EG, PER COL GRADIENT, ALBUMIN GRADIENT) FOR INSEMINATION OR DIAGNOSIS WITH SEMEN ANALYSIS INSEMINATION OF OOCYTES EXTENDED CULTURE OF OOCYTE(S)/EMBRYO(S), 4-7 DAYS ASSISTED OOCYTE FERTILIZATION, MICRO TECHNIQUE; LESS THAN OR EQUAL TO 10 OOCYTES ASSISTED OOCYTE FERTILIZATION, MICRO TECHNIQUE; GREATER THAN 10 OOCYTES SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM INCLUDING HUHNER TEST (POST COITAL) SEMEN ANALYSIS; MOTILITY AND COUNT (NOT INCLUDING HUHNER TEST) SEMEN ANALYSIS; COMPLETE (VOLUME, COUNT, MOTILITY AND DIFFERENTIAL) Page 4 of 5

5 89322 SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL USING STRICT MORPHOLOGIC CRITERIA (EG, KRUGER) SPERM ANTIBODIES G0123 G0306 G0307 S3655 SPERM EVALUATION; CERVICAL MUCUS PENETRATION TEST, WITH OR WITHOUT SPIONNBARKEIT TEST SPERM EVALUATION, FOR RETROGRADE EJACULATION, URINE (SPERM CONCENTRATION, MOTILITY, AND MORPHOLOGY, AS INDICATED) SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM) COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, SCREENING BY CYTOTECHNOLOGIST UNDER PHYSICIAN SUPERVISION COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, WITHOUT PLATELET COUNT) AND AUTOMATED WBC DIFFERENTIAL COUNT COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC; WITHOUT PLATELET COUNT) ANTISPERM ANTIBODIES TEST (IMMUNOBEAD) Please confirm member benefit for the following codes. Reimbursement is only available if the benefit is covered under the member's contract CRYOPRESERVACTION; EMBRYO(S) CRYOPRESERVATION; SPERM SPERM IDENTIFICATION FROM TESTIS TISSUE, FRESH OR CRYOPRESERVED BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICRO TECHNIQUE (FOR PRE IMPLANTATION GENETIC DIAGNOSIS); LESS THAN OR EQUAL TO 5 EMBRYOS BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICRO TECHNIQUE (FOR PRE IMPLANTATION GENETIC DIAGNOSIS); GREATER THAN 5 EMBRYOS SEMEN ANALYSIS, PRESENCE AND/OR MOTILITY OF SPERM CRYOPRESERVATION, REPRODUCTIVE TISSUE, TESTICULAR STORAGE (PER YEAR); EMBRYO(S) STORAGE (PER YEAR); SPERM/SEMEN THAWING OF CRYOPRESERVED; EMBRYO(S) THAWING OF CRYOPRESERVED; SPERM/SEMEN, EACH ALIQUOT G0027 SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM EXCLUDING HUHNER Page 5 of 5

M.D.IPA, M.D.IPA Preferred, Optimum Choice and Optimum Choice Preferred STAT Laboratory List Revised Jan. 5, 2017

M.D.IPA, M.D.IPA Preferred, Optimum Choice and Optimum Choice Preferred STAT Laboratory List Revised Jan. 5, 2017 If laboratory results are required on a STAT basis, the designated commercial medical laboratory