Effective June 1, 2018

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 10021 FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE 10022 FINE NEEDLE ASPIRATION; WITH IMAGING GUIDANCE 38220 BONE MARROW; ASPIRATION ONLY 38221 BONE MARROW BIOPSY, NEEDLE OR TROCAR 80047 BASIC METABOLIC PANEL (CALCIUM, IONIZED) 80048 BASIC METABOLIC PANEL 80053 COMPREHENSIVE METABOLIC PANEL 80500 80502 81000 81002 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 81025 URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISONMETHODS 82247 BILIRUBIN; TOTAL 82248 BILIRUBIN; DIRECT BLOOD, OCCULT BY PEROXIDASE ACTIVITY (EG, GUAIAC) QUALITATIVE; FECES, 1-3 82270 SIMULTANEOUS DETERMINATIONS 82272 BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING. 82565 CREATININE; BLOOD 82670 ESTRADIOL 82731 FETAL FIBRONECTIN, CERVICOVAGINAL SECRETIONS, SEMI-QUANTITATIVE GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO2 (INCLUDING CALCULATED O2 82803 SATURATION); 82805 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

82948 GLUCOSE; BLOOD, REAGENT STRIP 83002 GONADOTROPIN; LUTEINIZING HORMONE (LH) 83013 HELICOBACTER PYLORI ANALYSIS FOR UREASE ACTIVITY, NON-RADIOACTIVE ISOTOPE 83014 HELICOBACTER PYLORI; DRUG ADMINISTRATION AND SAMPLE COLLECTION 83036 HEMOGLOBIN; GLYCATED 83655 LEAD 83861 MICROFLUIDIC ANALYSIS UTILIZING AN INTEGRATED COLLECTION AND ANALYSIS DEVICE, TEAR OSMOLARITY 83986 PH; BODY FLUID, NOT OTHERWISE SPECIFIED 84144 PROGESTERONE 84520 UREA NITROGEN; QUANTITATIVE 85002 BLEEDING TIME 85004 BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT 85007 BOLLD SMEAR, MICROSCOPE EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT 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 (HGH, HCT, RBC, WBC AND PLATELET COUNT) 85032 BLOOD COUNT: MANUAL CELL COUNT (ERYTHROCYTE, LEUKOCYTE, PLATELET), EACH 85044 BLOOD COUNT; RETICULOCYTE, MANUAL 85060 BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT 85097 BONE MARROW, SMEAR INTERPRETATION 85576 PLATELET; AGGREGATION (IN VITRO), ANY AGENT 85610 PROTHROMBIN TIME 85651 SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED 86308 HETEROPHILE ANTIBODIES; SCREENING 86403 PARTICLE AGGLUTINATION; SCREEN, EACH ANTIBODY 86485 SKIN TEST, CANDIDA 86486 SKIN TEST; UNLISTED ANTIGEN, EACH 86510 SKIN TEST; HISTOPLASMOSIS 86580 SLIN TEST; TUBERCULOSIS, INTRADERMAL 87081 CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY 87205 87210 87220 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

87430 87624 87804 87809 87880 88142 88172 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) 88173 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 88177 EPISODE, SAME SITE 88300 LEVEL I SURGICAL PATHOLOGY, GROSS EXAMINATION ONLY LEVEL II SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION OF PRESUMPTIVELY 88302 NORMAL TISSUE(S); FOR IDENTIFICATION AND RECORD PURPOSES LEVEL III SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION OF PRESUMPTIVELT 88304 ABNORMAL TISSUE(S); UNCOMPLICATED SPECIMEN 88305 LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION 88307 LEVEL V - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION 88309 88311 88312 88313 88314 88319 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 88321 CONSULTATION AND REPORT ON REFERRED SLIDES PREPARED ELSEWHERE 88323 CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPARATION OF SLIDES CONSULTATION, COMPREHENSIVE, WITH REVIEW OF RECORDS AND SPECIMENS, WITH REPORT 88325 ON REFERRED MATERIAL 88329 PATHOLOGY CONSULTATION DURING SURGERY Page 3 of 5

88331 88332 88341 88342 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. 88346 IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; DIRECT METHOD 88347 IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; INDIRECT METHOD 88348 ELECTRON MICROSCOPY; DIAGNOSTIC 88349 ELECTRON MICROSCOPY; SCANNING 88355 MORPHOMETRIC ANALYSIS; SKELETAL MUSCLE 88356 MORPHOMETRIC ANALYSIS; NERVE 88358 MORPHOMETRIC ANALYSIS; TUMOR 88362 NERVE TEASING PREPARATIONS 88365 TISSUE IN SITU HYBRIDIZATION, INTERPRETATION AND REPORT 88371 PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION AND REPORT; 88372 89060 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) 89230 SWEAT COLLECTION BY IONTOPHORESIS 89250 CULTURE AND FERTILIZATION OF OOCYTE(S); 89251 CULTURE AND FERTILIZATION OF OOCYTE(S): WITH CO-CULTURE OF EMBRYOS 89253 ASSISTED EMBRYO HATCHING, MICROTECHNIQUES (ANY METHOD) 89254 OOCYTE IDENTIFICATION FROM FOLLICULAR FLUID 89255 PREPARATION OF EMBRYO FOR TRANSFER (ANY METHOD) 89257 SPERM IDENTIFICATION FROM ASPIRATION (OTHER THAN SEMINAL FLUID) 89260 89261 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 89268 INSEMINATION OF OOCYTES 89272 EXTENDED CULTURE OF OOCYTE(S)/EMBRYO(S), 4-7 DAYS 89280 ASSISTED OOCYTE FERTILIZATION, MICRO TECHNIQUE; LESS THAN OR EQUAL TO 10 OOCYTES 89281 ASSISTED OOCYTE FERTILIZATION, MICRO TECHNIQUE; GREATER THAN 10 OOCYTES 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; COMPLETE (VOLUME, COUNT, MOTILITY AND DIFFERENTIAL) Page 4 of 5

89322 SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL USING STRICT MORPHOLOGIC CRITERIA (EG, KRUGER) 89325 SPERM ANTIBODIES 89330 89331 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. 89258 CRYOPRESERVACTION; EMBRYO(S) 89259 CRYOPRESERVATION; SPERM 89264 SPERM IDENTIFICATION FROM TESTIS TISSUE, FRESH OR CRYOPRESERVED BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICRO TECHNIQUE (FOR PRE- 89290 IMPLANTATION GENETIC DIAGNOSIS); LESS THAN OR EQUAL TO 5 EMBRYOS BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICRO TECHNIQUE (FOR PRE- 89291 IMPLANTATION GENETIC DIAGNOSIS); GREATER THAN 5 EMBRYOS 89321 SEMEN ANALYSIS, PRESENCE AND/OR MOTILITY OF SPERM 89335 CRYOPRESERVATION, REPRODUCTIVE TISSUE, TESTICULAR 89342 STORAGE (PER YEAR); EMBRYO(S) 89343 STORAGE (PER YEAR); SPERM/SEMEN 89352 THAWING OF CRYOPRESERVED; EMBRYO(S) 89353 THAWING OF CRYOPRESERVED; SPERM/SEMEN, EACH ALIQUOT G0027 SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM EXCLUDING HUHNER Page 5 of 5