CurrentHealth NetPolicy CC.PP.055

Physician's Office Laboratory Testing (in-office STAT lab code list)

Defines payment and reimbursement criteria for in-office (physician office) laboratory procedures limited to codes listed on the plan's Short Turnaround Time (STAT) laboratory code list; applies to physicians and other qualified health professionals submitting claims to the health plan.

Policy Summary

PayerHealth Net

PolicyPhysician's Office Laboratory Testing (in-office STAT lab code list)

Policy CodePolicy CC.PP.055

Change TypeAdministrative review / minor operational notes

Effective Date

Next Review Date

Key ActionRefer non-STAT in-office laboratory procedures to an independent contracted laboratory because automated adjudication will deny non-STAT in-office claims.

SourceLink

POLICY UPDATE CHANGES

Added note to reimbursement section that additional requirements from other policies may apply, even for the procedure codes considered payable in the physician's office.

Conducted annual review, updated policy dates, removed deleted code C9803.

Conducted annual review and removed deleted codes (08/29/2023).

STAT listCodes enumerated as payable in-office

Auto-denyAutomated denial for non-STAT

Physicians & QHPsApplies to

11/2024Policy last revised

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.

In-Office Laboratory Coverage Rules

In-office laboratory coverage criteria

Reimbursement and adjudication criteria for in-office (physician office) laboratory procedures.

Reimbursement is limited to laboratory procedures whose CPT/HCPCS codes appear on the Short Turnaround Time (STAT) laboratory code list included in this policy.

Laboratory procedures performed in the physician office (location 11) that are NOT on the STAT lab list are not payable and must be referred to an independent, contracted laboratory provider.

Claims for in-office (location 11) laboratory procedures that are not included on the STAT lab list will be denied by the health plan's automated claims adjudication system.

Additional requirements from other payment policies may apply to procedures on the STAT list; providers must meet any such requirements for payment to occur.

General coverage rules and precedence

Coverage and payment determinations are subject to plan documents, legal/regulatory requirements, and applicable Medicare or state rules.

Coverage and payment determinations and administration of benefits are governed by the terms, conditions, exclusions and limitations of the member's coverage documents (for example, evidence of coverage, certificate of coverage, policy or contract).

Coverage and payment determinations are subject to applicable state and federal requirements and to plan-level administrative policies and procedures; Health Plan may change, amend or withdraw this payment policy at any time.

Special program precedence

For Medicare members, applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) must be reviewed and take precedence when applying this policy's criteria.
For Medicaid members, state Medicaid coverage provisions take precedence over this payment policy when there is a conflict; refer to the state Medicaid manual for applicable coverage provisions.

This payment policy is a guideline to assist coverage and payment decisions and does not constitute a contract or guarantee of payment or of clinical care; providers are expected to exercise independent professional judgment in treating members.

Procedure Codes and Coding Guidance

STAT laboratory procedures (selected examples)CPTCovered

0202U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA); 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
0223U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
0224U	Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); includes titer(s) when performed.
80305	Drug test(s), presumptive, any number of drug classes; capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges); includes sample validation when performed, per date of service.
81000	Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy.
82947	Glucose; quantitative, blood.
83036	Hemoglobin; glycosylated (A1C).
84703	Gonadotropin, chorionic (hCG); qualitative.
86580	Skin test; tuberculosis, intradermal.
87635	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) amplified probe technique.

Allowable/Referenced Procedure CodesmixedCovered

87400	Infectious agent antigen detection by immunoassay; Influenza A or B.
87426	Infectious agent antigen detection by immunoassay; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2).
87428	Infectious agent antigen detection by immunoassay; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2).
87430	Infectious agent antigen detection by immunoassay; Streptococcus group A.
87490	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique.
87635	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) amplified probe technique.
87811	Infectious agent antigen detection by immunoassay with direct optical observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
G0480	Test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, requiring stable isotope or other universally recognized internal standards in all samples, and method- or drug-specific calibration and matrix-matched quality control material; qualitative or quantitative.
G0659	Test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, performed without method- or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug metabolite or drug class per specimen; qualitative or quantitative.
Q0111	Wet mounts, including preparations of vaginal, cervical or skin specimens.

inv-05: Location restriction — reimbursement limited to in-office procedures on the STAT list; non-listed in-office procedures not payable and referral guidance

In-office reimbursement limitationReimbursement for in-office laboratory procedures is limited to CPT/HCPCS codes listed on the STAT laboratory procedure code list; procedures not on the STAT list are not payable in-office.

Non-STAT in-office proceduresLaboratory procedures not included on the STAT lab list may not be performed in the office and should be referred to an independent contracted lab provider.

Referral expectationWhen a test is not on the STAT list, providers should refer the specimen to an independent or contracted laboratory for performance and billing.

Additional policy requirementsAdditional requirements from other policies may apply even for procedure codes considered payable in the physician's office.

Provider Obligations and Billing Actions

Denial Risk

Automated Denial and Referral Requirement

Reimbursement for in-office (location 11) laboratory procedures is limited to those codes listed in the STAT laboratory procedure code list (see the Coding and Modifier Information section). Laboratory procedures not included on the STAT lab list may not be performed in the office and must be referred to an independent or contracted laboratory. Additional requirements from other policies may apply, even for procedure codes considered payable in the physician's office.

In-office (location 11) lab procedures not on STAT list will be denied by automated adjudication
Providers must refer non-STAT lab services to independent/contracted laboratories
Check Coding and Modifier Information section for the STAT laboratory procedure code list

Note

Provider Obligations and Applicability

Providers are expected to follow the terms of the member's plan and this payment policy when submitting claims. Coverage and payment determinations are subject to all plan terms, conditions, exclusions and limitations as set forth in the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance), and to applicable state and federal requirements and plan-level administrative policies and procedures. This policy is not a guarantee of payment, does not constitute medical advice, and does not dictate clinical practice. Providers remain responsible for exercising professional medical judgment and for the medical advice and treatment of members. Health Plan retains the right to change, amend or withdraw this payment policy and to determine the effective date of the policy; legal and regulatory requirements supersede in case of discrepancy.

Key Definitions

inv-09: Definition — STAT laboratory procedures: tests needed immediately during a face-to-face encounter to manage urgent or emergent conditions

STAT procedure purposeTests needed immediately during a face-to-face encounter to manage medical emergencies or urgent conditions and designated appropriate for performance in the office.

Clinical use caseUsed when a provider determines diagnostic lab testing is necessary during the encounter to establish a diagnosis and/or select treatment to manage the patient's care.

Policy intentTo define payment criteria for in-office laboratory procedures and to encourage specialization of independent labs for higher-quality testing.

inv-10: Definition — CPT codes referenced for coding and reimbursement guidance (informational; inclusion does not guarantee coverage)

CPT/HCPCS referenceCurrent Procedural Terminology (CPT) and HCPCS codes are referenced for coding and reimbursement guidance; inclusion of a code in the policy is informational and does not guarantee coverage.