CurrentArizona Complete HealthPolicy CC.PP.055

Physician's Office Laboratory Testing (In‑Office / STAT Lab Procedures)

Defines payment and reimbursement criteria for laboratory tests performed in physician offices (in-office/STAT testing) and applies to physicians and other qualified health professionals submitting claims to Arizona Complete Health.

Policy Summary

PayerArizona Complete Health

PolicyPhysician's Office Laboratory Testing (In‑Office / STAT Lab Procedures)

Policy CodePolicy CC.PP.055

Change TypeNo material change

Effective DateNov 1, 2017

Next Review DateN/A

Key ActionDo not submit or expect reimbursement for in-office (location 11) laboratory procedure codes unless they are listed on the STAT laboratory procedure code list; refer other tests to an independent contracted lab.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

location 11Denied in-office location

STAT listAllowed in-office codes

ProvidersApplies to

ExtensiveCode list size

CPT/HCPCSReference

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In-Office (STAT) Laboratory Coverage Criteria

In-office laboratory coverage criteria

Payment and coverage for in-office (location 11) laboratory testing are allowed only when the procedure code is included on the STAT laboratory procedure code list. Automated adjudication will deny non-listed in-office lab claims and such testing should be referred to an independent, contracted laboratory.

ALL of the following

Procedure is performed in-office (place of service = 11).
The CPT or HCPCS procedure code billed is included on the STAT laboratory procedure code list published in this policy.
If the procedure code is NOT on the STAT laboratory procedure code list, the automated claims adjudication system will deny the in-office (location 11) claim and the test should be referred to an independent, contracted laboratory provider.

Coverage descriptors and administrative notes

Descriptors clarify definitive drug testing methods, specimen preparation codes, and administrative caveats regarding the scope and applicability of this payment policy.

ALL of the following

Definitive drug testing codes (e.g., G0482, G0483, G0659) are defined by analytic method and quality control requirements as described in the STAT code descriptors; each is billed per day and includes specimen validity testing.
Examples
- G0482: Definitive drug test for 8–14 drug classes using methods such as GC/MS or LC/MS with stable isotope/internal standards and method- or drug-specific calibration and matrix-matched QC; includes specimen validity testing, per day.
- G0483: Definitive drug test for 15–21 drug classes using methods such as GC/MS or LC/MS with stable isotope/internal standards and method- or drug-specific calibration and matrix-matched QC; includes specimen validity testing, per day.
- G0659: Definitive drug test for any number of drug classes performed without method- or drug-specific calibration, without matrix-matched QC, or without stable isotope/internal standards; includes specimen validity testing, per day.

STAT Laboratory Procedure Codes and Coding Notes

STAT laboratory procedure code list (examples)CPT | HCPCS | mixedCovered

80305-80377	Drug test(s), presumptive and definitive panels and related drug testing codes
83992, 81000-81015, 81025, 82043-82044, 82247-82272	Urinalysis, fecal occult blood, albumin and bilirubin testing codes
82465, 82565, 82731, 82947-82952, 82962, 83036-83037	Cholesterol, creatinine, fetal fibronectin, glucose tests, A1C
83655, 83986, 84132, 84703, 85013-85027, 85049	Lead, pH, potassium, hCG, blood count and hematology codes
85610, 85651, 86308, 86580, 86756	Coagulation, sedimentation rate, heterophile antibodies, skin test, RSV antibody
87070, 87172, 87205, 87210, 87220, 87270, 87490-87492, 87802-87808, 87880, 87905	Cultures, smears, wet mounts, infectious agent detection by various methods
G0480-G0483, G0659, Q0111-Q0112	Definitive drug testing (GC/MS, LC/MS) and wet mount/KOH preparations

Representative lab test descriptorsHCPCS | mixedCovered

G0482	Drug test(s), definitive, 8-14 drug classes, uses GC/MS or LC/MS with internal standards and matrix-matched QC; includes specimen validity testing, per day
G0483	Drug test(s), definitive, 15-21 drug classes, uses GC/MS or LC/MS with internal standards and matrix-matched QC; includes specimen validity testing, per day
G0659	Drug test(s), definitive, any number of drug classes, performed without method- or drug-specific calibration, without matrix-matched QC, or without stable isotope/internal standard(s); includes specimen validity testing, per day
Q0111	Wet mounts, including preparations of vaginal, cervical or skin specimens
Q0112	Potassium hydroxide (KOH) preparations

Allowed setting

Allowed in-office testsOnly CPT/HCPCS procedures listed on the policy's Short Turnaround Time (STAT) laboratory procedure code list are eligible for performance and reimbursement in a physician's office (in-office).

Referral requirementLaboratory procedures not included on the STAT lab list must be referred to an independent, contracted laboratory provider for testing and reimbursement.

Automated adjudication effectThe health plan's automated claims adjudication system will deny in-office (location 11) laboratory procedure claims when the procedure code is not on the STAT lab list.

Drug-class testing ranges

G0482Definitive drug test(s) — 8–14 drug classes (includes specimen validity testing), uses GC/MS or LC/MS with stable isotope/internal standards and matrix‑matched QC; billed per day.

Provider Responsibilities and Billing Actions

Denial Risk

Claim Denial and Referral Rule

The health plan's automated claims adjudication system will deny in-office (location 11) laboratory procedure claims when the procedure code is not included on the STAT laboratory procedure code list. Laboratory procedures not on the STAT list may not be performed in the office and should be referred to an independent, contracted laboratory provider.

Automated denial applies to services billed with Place of Service 11 (in-office) when the CPT/HCPCS code is not on the STAT laboratory procedure code list.
Providers must refer tests not on the STAT list to an independent, contracted lab for processing and billing.

Note

Policy Administration and Provider Responsibilities

For the purposes of this payment policy, “Health Plan” means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plan’s affiliates, as applicable. This payment policy is a guide to payment and does not constitute a contract or guarantee of payment. Coverage and payment determinations and the administration of benefits are subject to the terms, conditions, exclusions and limitations of the member’s coverage documents and to applicable state and federal requirements, as well as plan-level administrative policies and contracted laboratory arrangements. The Health Plan may change, amend, or withdraw this payment policy at any time; updates will be effective as determined by the Health Plan and may be subject to legal and regulatory notification requirements.

Definitions

STAT laboratory tests

DefinitionSTAT laboratory tests are those laboratory tests designated as necessary to be performed immediately during a face-to-face encounter to manage medical emergencies or urgent conditions; specific CPT/HCPCS codes listed in this policy are considered appropriate for in-office performance.

Appropriate settingDesignated tests on the STAT list may be performed in-office when needed to manage urgent clinical decisions during the patient encounter.

Scope examplesRepresentative CPT/HCPCS entries include definitive drug testing codes (e.g., G0482, G0483, G0659) and specimen preparation codes (e.g., Q0111, Q0112) described in the policy.

Short Turnaround Time Lab Procedure

DefinitionShort Turnaround Time (STAT) lab procedures are laboratory tests and services needed immediately to manage urgent or emergent medical situations.

Clinical use

Policy Summary

PayerArizona Complete Health

PolicyPhysician's Office Laboratory Testing (In‑Office / STAT Lab Procedures)

Policy CodePolicy CC.PP.055

Change TypeNo material change

Effective DateNov 1, 2017

Next Review DateN/A

SourceLink

On This Page

Specimen preparation and microscopic procedures are described by specific HCPCS codes (e.g., Q0111 = wet mounts; Q0112 = KOH preparations).

This payment policy is a guide to payment and does not constitute a contract or guarantee of payment; coverage and payment determinations are subject to the terms of coverage documents, applicable state Medicaid provisions, and any applicable Medicare NCDs/LCDs. State Medicaid provisions and NCDs/LCDs take precedence where applicable.

Providers retain independent professional medical judgment and are responsible for medical advice and treatment; providers are independent contractors and this policy is not intended to dictate clinical care.

G0483Definitive drug test(s) — 15–21 drug classes (includes specimen validity testing), uses GC/MS or LC/MS with stable isotope/internal standards and matrix‑matched QC; billed per day.

G0659Definitive drug test(s) — any number of drug classes (includes specimen validity testing), performed without method- or drug-specific calibration, without matrix‑matched QC, or without stable isotope/internal standards; billed per day.

Providers are expected to follow plan, administrative, state and federal rules and any contracted lab arrangements.
This policy does not dictate medical practice; providers must exercise clinical judgment and comply with applicable coverage documents.

Used when immediate results are necessary during a face-to-face encounter to establish a diagnosis or select treatment to manage the patient's care.

Relation to STAT listOnly procedures designated as STAT in the policy's code list are permitted to be performed and reimbursed in-office.

Independent Laboratory

DefinitionIndependent Laboratory: a laboratory that is independent of an attending or consulting physician's office and of a hospital.

Role in policyLaboratory procedures not on the STAT list must be referred to an independent laboratory for performance and reimbursement.

PurposeEncourages use of specialized independent labs to ensure higher quality testing in the appropriate setting.

Contracted Laboratory Provider

DefinitionContracted Laboratory Provider: a provider that has entered into an agreement with the health plan to provide laboratory services at a reduced rate to the insurer's or administrator's clients.

Referral destinationWhen tests are not permitted in-office (not on the STAT list), they should be sent to a contracted laboratory provider for testing and billing.

Financial implicationContracted status indicates the lab provides services under an agreement with the health plan, typically at negotiated/reduced rates.