M.D.IPA, M.D.IPA Preferred, Optimum Choice and Optimum Choice Preferred STAT Laboratory List Revised Jan. 5, 2017
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1 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 can arrange a STAT pick-up and reporting. If you perform a STAT test and bill for the service for a member, the prescription must indicate STAT. Please use the ST or ET modifier with the CPT code for the test. Additionally, the diagnosis indicated on the claim must support the STAT billing. STAT services must be done by a participating practitioner for HMO members. Please reference the following STAT laboratory list to determine if the laboratory code is listed. If you have questions, please contact Provider Services at CPT Code Electrolyte panel must include the following: Carbon dioxide (bicarbonate) (82374) Chloride (82435) Potassium (84132) Sodium (84295) Electrolyte panel must include the following: Carbon dioxide (bicarbonate) (82374) Chloride (82435) Potassium (84132) Sodium (84295) Comprehensive metabolic panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520) Obstetric panel must include the following: Blood count, complete (CBC), automated and automated differential WBC count (85025 or and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Hepatitis B surface antigen (HBsAg) (87340) Antibody, rubella (86762) Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592) Antibody screen, RBC, each serum technique (86850) Blood typing, ABO (86900) AND Blood typing, Rh (D) (86901) Renal function panel must include the following: Albumin (82040) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus inorganic (phosphate) (84100) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520)
2 80074 Acute hepatitis panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709) Hepatitis B core antibody (HBcAb), IgM antibody (86705) Hepatitis B surface antigen (HBsAg) (87340) Hepatitis C antibody (86803) Hepatic function panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Obstetric panel (includes HIV testing) Drug screen, qualitative; multiple drug classes chromatographic method, each procedure Carbamazepine; total Digoxin Digoxin; free Valproic acid (dipropylacetic acid); free Lithium Phenobarbital Sirolimus Theophylline 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 Alcohols Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, urobilinogen, any number of these constituents; non-automated, with Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, urobilinogen, any number of these constituents; automated, with
3 81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, urobilinogen, any number of these constituents; non-automated, without Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, urobilinogen, any number of these constituents; automated, without Urinalysis; qualitative or semi-quantitative, except immunoassays Urinalysis; bacteriuria screen, except by culture or dipstick Urinalysis; microscopic only Urine pregnancy test, by visual color comparison methods Amines, vaginal fluid, qualitative Amylase Bilirubin; total Bilirubin; direct 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) Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; other sources Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening Calcium; total Carbon dioxide (bicarbonate) Chloride; blood Creatine kinase (CK), (CPK); total Creatinine; blood Gases, blood, ph only Gases, blood, O2 saturation only, by direct measurement, except pulse oximetry
4 82947 Glucose; quantitative, blood (except reagent strip) Glucose; blood, reagent strip Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semi-quantitative, multiple step method Lactate dehydrogenase (LD), (LDH) Lead Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity Phenylalanine (PKU), blood Phosphatase, alkaline Phosphorus inorganic (phosphate) Potassium; serum, plasma or whole blood Sodium; serum, plasma or whole blood Transferase; aspartate amino (AST) (SGOT) Transferase; alanine amino (ALT) (SGPT) Urea nitrogen; quantitative Urea nitrogen, clearance Uric acid; blood Gonadotropin, chorionic (hcg); quantitative Gonadotropin, chorionic (hcg); qualitative 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 (Hgb, Hct, RBC, WBC and platelet count) Prothrombin time
5 85730 Thromboplastin time, partial (PTT); plasma or whole blood Thromboplastin time, partial (PTT); substitution, plasma fractions Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (e.g., reagent strip) 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 (e.g., saline, India ink, KOH preps) Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (e.g., scabies) Infectious agent antigen detection by immunoassay with direct optical observation; Influenza Infectious agent antigen detection by immunoassay with direct optical observation; adenovirus Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site Cytopathology, evaluation of fine needle aspirate; interpretation and report Semen analysis; presence and/or motility of sperm including Huhner test (post coital) Q0111 Wet mounts, including preparations of vaginal, cervical or skin specimens Q0112 All potassium hydroxide (KOH) preparations Information contained within is confidential and proprietary and may not be shared with individuals outside of the intended receiver s practice and/or facility. These codes are subject to change and your contract may differ from this list.
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