CurrentFidelis CarePolicy FC.CG.PP.08

Outpatient Laboratory Services Payment Policy

Governs reimbursement and billing requirements for outpatient laboratory services (excluding genetic and molecular testing) for Fidelis Care products including Medicaid and Health Insurance Marketplace.

Policy Summary

PayerFidelis Care

PolicyOutpatient Laboratory Services Payment Policy

Policy CodePolicy FC.CG.PP.08

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionInclude appropriate and accurate diagnosis codes, ordering and rendering provider information, and date and place of service on all claim transactions to avoid payment denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

genetic & moleculartests excluded from this policy

CPT 80000, PLA, MAAA, HCPCS IIcoding sections addressed

Medicaid & Marketplaceproduct types

02/28/2025last revision

Coverage and Billing Criteria

Coverage and billing criteria

Coverage and payment are conditional on correct coding, documentation, and adherence to coding edits and panel/PLA/MAAA billing rules.

Bill for the test performed as indicated on the test requisition form and delivered on the test result.

Include appropriate and accurate ICD diagnosis codes; 3-digit headers may be insufficient and can be denied for lack of specificity.

Include ordering and rendering provider information on all claim transactions.

Include the date and place of service on all claim transactions to distinguish outpatient testing from emergency department or inpatient services.

When a test evaluates multiple analytes with a consolidated procedure, report only one unit of an appropriate CPT/HCPCS/PLA code unless multiple units or modifiers are appropriate (e.g., repeat testing, multiple specimens).

Policy Summary

PayerFidelis Care

PolicyOutpatient Laboratory Services Payment Policy

Policy CodePolicy FC.CG.PP.08

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionInclude appropriate and accurate diagnosis codes, ordering and rendering provider information, and date and place of service on all claim transactions to avoid payment denial.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Accepted Codes and Edits

Accepted coding sectionsmixed

80000 series	Pathology and Laboratory Procedures (CPT)
U codes	Proprietary Laboratory Analyses (PLA)
M codes	Category III Multianalyte Assays with Algorithmic Analyses (MAAA)
Level II HCPCS	HCPCS Level II codes for laboratory services

CPT/PLA/MAAA/Level II HCPCS (summary)mixed

80000 series	Pathology and Laboratory Procedures (CPT)
U codes	Proprietary Lab Analysis (PLA)
M codes	Category III Multianalyte Assays with Algorithmic Analyses (MAAA)
Level II HCPCS	Level II Healthcare Common Procedure Coding System (HCPCS)

Medically Unlikely Edit (MUE)

MUE summaryUnits billed must not exceed the maximum units of service (MUE) defined for the HCPCS/CPT code; MUE represents the maximum UOS reported for the vast majority of appropriately reported claims by the same provider for the same beneficiary on the same date of service.

When MUE appliesApplies when a code falls under a Medically Unlikely Edit; not all HCPCS/CPT codes have an MUE.

Interaction with modifiersIf a code is subject to NCCI PTP edits or MUEs, billing must comply with those edits; modifiers may be used only as allowed by NCCI guidance.

Related editsProcedure-to-Procedure (PTP) edits and MUE requirements are enforced together; PTP edits prohibit mutually exclusive procedures when billed together.

Claim Submission & Billing Instructions

Documentation Required

Claim submission requirements: required claim fields and documentation

Include appropriate and accurate diagnosis codes related to the procedure performed; 3-digit ICD headers may lack specificity and can be denied for insufficient specificity. Ensure ordering and rendering provider information is present on all claim transactions. Include the date and place of service on all claims so outpatient testing can be distinguished from ED or inpatient services. Bill for the test performed as indicated on the test requisition form and delivered on the test result; failure to include these required fields and documentation may result in claim denial or nonpayment.

Bill for the test performed as indicated on the test requisition form and delivered on the test result.
Include appropriate and accurate diagnosis codes (3-digit ICDs may be insufficient).
Include ordering and rendering provider information on all claim transactions.
Include date and place of service on all claim transactions.

Billing Rule

Billing for interpretation-only services: use Modifier 52

When interpretation of existing data from a separate test is performed without performing the wet lab procedures, bill the service using Modifier 52 to indicate reduced services and an adjusted rate.

Use Modifier 52 when the interpretation is performed but wet lab procedures were not performed.

OpenPayer

Outpatient Laboratory Services Payment Policy

Coverage and Billing Criteria

Accepted Codes and Edits

Claim Submission & Billing Instructions

Definitions