All new CPT-4 and HCPCS laboratory codes, unless otherwise specified, have the following diagnosis excludes: V70, V70.0, V70.5, V70.6, V70.7, V70.8, V70.9, V72, V72.1, V72.6 and V72.9.
HCPCS codes G0416 - G0419 (surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling) are Medi-Cal benefits and may not be billed together during the same session nor with CPT-4 codes 88300 - 88309.
Codes G0416 - G0419 are split-billable and must be billed with appropriate modifier 26, 99, TC or ZS.
The following codes are not split-billable and must not be billed with modifiers 26, 99, TC or ZS: S3860, S3862, 83876, 83951, 85397, 87905, 88720, 88740 and 88741.
HCPCS codes S3860 and S3862 (genetic testing) require a TAR and are once-in-a-lifetime tests.
HCPCS code S3862 (genetic testing, family-specific ion channel analysis) requires a TAR that must include the following documentation:
- The family member being tested is a Medi-Cal recipient, and
- There is clinical documentation of at least one first-degree relative (parent, sibling or offspring) with a laboratory-confirmed LQTS genetic mutation
CPT-4 code 83876 (myeloperoxidase [MPO]) is a Medi-Cal benefit for patients with ischemic heart disease and must be billed with a diagnosis in the range of ICD-9-CM codes 410 - 414.9.
CPT-4 code 83925 (opiates[s], drug and metabolites, each procedure) requires documentation that a prior drug screen was positive for opiates.
CPT-4 code 83951 (oncoprotein; des-gamma-carboxy-prothrombin [DCP]) must be billed with an ICD-9-CM diagnosis within one of the ranges below:
ICD-9-CM Code Description
- 070.20 - 070.9 Viral hepatitis
- 150.00 - 155.2 Malignant neoplasm of esophagus, stomach, small intestine, colon, rectum or liver
- 570.00 - 571.9 Acute and subacute necrosis of liver or chronic liver disease and cirrhosis
CPT-4 code 87905 (infectious agent enzymatic activity other than virus) is a CLIA and is billed with modifier QW.
Deleted and Replacement Code
The policy of the deleted code applies to the replacement.
- Deleted Code: 88400
- Replacement Code: 88720