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Billing for lab procedures

Priority Health will reimburse participating providers for the following tests when performed in provider office laboratories if the results are needed immediately for clinical decisions or HEDISĀ®. 

Participating labs

Any test not on the list below should be referred to a participating Joint Venture Hospital Lab in the East Region, or (in West and North Michigan) participating hospital labs or Quest Diagnostics, Inc., as designated by the patient's primary care physician.
Go to guidelines for billing non-participating (reference) lab procedures

Approved physician office laboratory tests

  • If a lab test is not listed here, it is NOT eligible for reimbursement when performed in a physician's office.
  • Physician office labs with Waived CLIA licenses may only perform waived tests, indicated by an asterisk (*).

Code
Description
80048
Basic metabolic panel
This panel must include the following: Calcium, total (82310), Carbon dioxide (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Potassium (84132), Sodium (84295), Urea nitrogen (BUN) (84520)
80053
Comprehensive metabolic panel
This 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)
80061
Lipid panel
80101
Drug screen, qualitative; single drug class method (eg, immunoassay, enzyme assay), each drug class
81000
Urinalysis w/micro
81001
Urinalysis, automated, w/micro
81002*
Urinalysis w/o micro
81003
Urinalysis, dip stic/tab, automated w/o micro
81015
Urinalysis, micro only
81025*
Urine pregnancy, color comparison
81050
Urinalysis, volume measurement for timed collection, each
82042
Albumin; urine or other source, quantitative, each specimen
82043
Albumin; urine, microalbumin, quantitative
82044
Albumin; urine, microalbumin, semiquantitative (eg, reagent strip assay)
82270*
Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided three cards or single triple card for consecutive collection)
82272
Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, single specimen (eg, from digital rectal exam)
82274
Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations
G0107
Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations
82947
Glucose; quantitative, blood (except reagent strip)
82948
Glucose, reagent strip
82950
Post-glucose dose
82962*
Glucose, home use device
83026*
Hemoglobin, copper sulfate method
83036
Hemoglobin; glycosylated (A1C)
83037
Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use
83655
Lead testing
83721
Lipoprotein, direct measurement; direct measurement, LDL cholesterol
84132
Potassium; serum
84155
Protein, total, except by refractometry; serum
84160
Protein, total, by refractometry, any source
84165
Protein, electrophoretic fractionation & quantitation
85007
Blood smear w/manual diff
85013*
Spun microhematocrit
85014
Non-spun microhematocrit
85018
Hemoglobin
85025
CBC, automated and automated differential
85027
Complete CBC, automated
85610
Prothrombin time
85651*
Sedimentation rate, non-automated
86308
Heterophile antibodies, screening
86403
Particle agglutination, screen/mononucleosis
86580
Tuberculosis, intradermal
86585
Tuberculosis, tine test
87077
Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate
87101
Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail
87210
Wet mount, bacteria/fungi (wet prep)
87220
Tissue exam for fungi (KOH)
87275
Influenza B (immunofluorescent)
87276
Influenza A (immunofluorescent)
87400
Influenza A or B (enzyme immunoassay)
87430
Streptococcus, group A
87804
Influenza - infectious agent (immunoassay) w/direct optical observation
87807
Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus
87808
Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis
87880
Streptococcus group A
87905
Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid)
89190
Nasal smear for eosinophils
Tests generally performed only by specialist physicians:
87168
Macroscopic examination; arthropod (approved for dermatologists only)
88161
Cytopathology, smears, any other source; preparation, screening and interpretation (approved for dermatologists only)
88173
Eval fine needle aspirate, interpretation & report
88300
Surgical pathology, Level I
88302
Surgical pathology, Level II
88304
Surgical pathology, Level III (skin - cyst/tag/debridement)
88305
Surgical pathology, Level IV (skin - other than cyst/tag/debridement)
88342
Immunohistochemistry (including tissue immunoperoxidase), each antibody
85097
Smear interpretation only (to be billed with 85095)
89060
Crystal identification, micro
89300
Semen analysis, presence & motility
89310
Sperm count & motility
89320
Semen analysis; complete (volume, count, motility, and differential)
89322
Semen analysis; volume, count, motility, and differential using strict morphologic criteria (e.g., Kruger)
89325
Sperm antibodies

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). *Indicates CLIA-waived tests.
Last modified 05/04/10