CurrentHealth NetPolicy CC.PP.055

Payment Policy: Physician's Office Lab Testing

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

Policy Summary

PayerHealth Net

PolicyPayment Policy: Physician's Office Lab Testing

Policy CodePolicy CC.PP.055

Change TypeAnnual review

Effective Date

Next Review Date

Key ActionClaims for in-office laboratory procedures not on the STAT lab list will be denied by the automated claims adjudication system.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

DenialAutomated denials for non-STAT codes

STAT list onlyReimbursement restriction

Physicians & QHPsApplies to

~100+Listed codes

07/2025Last 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 testing coverage criteria

Covered when ALL of the following are met:

ALL of the following

The performance of in-office (physician office, location 11) laboratory testing is limited to the CPT and HCPCS codes listed in the Short Turnaround Time (STAT) laboratory code list included in this policy.
Operational constraint: procedures not on the STAT list should be referred to an independent, contracted laboratory provider.
Reimbursement is limited to codes listed on the STAT laboratory procedure code list (see the Coding and Modifier Information section).
Additional requirements from other policies may apply, even for procedure codes considered payable in the physician's office.
The health plan's automated claims adjudication system will deny in-office (location 11) laboratory procedures that are not included on the STAT lab list defined in this policy.
Claims for disallowed in-office lab procedures should be submitted to an independent laboratory as appropriate.
This payment policy provides guidance for payment determinations and administration of benefits; coverage and payment remain subject to the terms, conditions, exclusions and limitations of the member’s coverage documents and applicable law.
The policy does not guarantee payment and may be amended by the Health Plan.

Allowable procedure codes and policy application

Application and allowable procedure codes — the following notes govern application of the STAT list and historical updates:

note":"The automated adjudication system will deny claims for non-STAT codes submitted with an office location (11)."},{"text":"This policy’s allowable-code determination interacts with other payment and coverage policies; presence on the STAT list does not override other policy-specific requirements (e.g., prior authorization, documentation, or contract exclusions).","note":"Providers should confirm other applicable policy conditions before performing and billing STAT-listed procedures in-office."}]}

Code Lists and Coding Rules

STAT laboratory procedure code list (examples)mixedCovered

0115U	Respiratory infectious agent detection by nucleic acid (DNA and RNA), 18 viral types and subtypes and 2 bacterial targets
0202U	Infectious disease pathogen-specific nucleic acid, 22 targets including SARS-CoV-2, qualitative RT-PCR
0224U	Antibody, SARS-CoV-2, includes titer(s) when performed
80305	Drug test(s), presumptive, any number of drug classes, read by direct optical observation
80307	Drug test(s), presumptive, by instrument chemistry analyzers or mass spectrometry
81000	Urinalysis by dip stick or tablet reagent with microscopy
83036	Hemoglobin; glycosylated (A1C)
84484	Troponin, quantitative
85025	Blood count; complete (CBC), automated

Allowable/Referenced laboratory procedure codesCPT | HCPCS | mixedCovered

87428	Infectious agent antigen detection by immunoassay; SARS-CoV-2 and influenza A/B
87635	Infectious agent detection by nucleic acid; SARS-CoV-2, amplified probe technique
87636	SARS-CoV-2 and influenza A/B, multiplex amplified probe technique
87811	Infectious agent antigen detection by immunoassay with direct optical observation; SARS-CoV-2
G0480	Definitive drug test(s) utilizing GC/MS or LC/MS, 1-7 drug classes
U0001	CDC 2019-nCoV real-time RT-PCR diagnostic panel

Place of service restriction

Reimbursement limitationReimbursement for in-office laboratory procedures is limited to CPT/HCPCS codes listed on the policy's STAT laboratory procedure code list.

Referral requirementLaboratory procedures not included on the STAT list should be referred to an independent, contracted lab provider.

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

Multiplex target count thresholds

3–5 targetsCPT 87505 — multiplex amplified probe technique for multiple types/subtypes, 3-5 targets.

6–11 targetsCPT 87506 / descriptors in 87632–87633 — multiplex amplified probe technique for multiple types/subtypes, 6-11 targets.

12–25 targetsCPT 87507 / CPT 87633 — multiplex amplified probe technique for multiple types/subtypes, 12-25 targets.

Provider Billing and Compliance Actions

Denial Risk

Automated claim denial for non-STAT in‑office labs

The health plan's automated claims adjudication system will deny in‑office (location 11) laboratory procedures that are not included on the plan's STAT lab list. Providers should verify that any specimen collection or testing performed in an office setting (POS 11) is on the approved STAT list prior to billing to avoid automatic claim denial.

Affected location: Place of Service 11 (office)
Triggers automated denial for non-STAT in-office labs
Action: confirm test is on Health Plan STAT lab list before performing and billing

Prior Authorization

Regulatory compliance and prior review

Providers are responsible for reviewing and complying with all applicable national and local coverage determinations (NCDs/LCDs), state Medicaid rules (which may take precedence where applicable), and plan-specific requirements before performing or billing for services. This policy is a payment guide and does not replace coverage rules in the member's benefit contract or legal/regulatory requirements; when discrepancies exist, applicable law and regulation govern. Prior review or authorization requirements established by the plan or by NCDs/LCDs must be followed to ensure coverage and payment.

Review relevant NCDs and LCDs for the service being billed
Note: state Medicaid rules may supersede this policy where applicable
Obtain any required prior authorization or prior review per plan procedures before performing services

Definitions and Key Terms

STAT laboratory procedures

DefinitionTests needed immediately to manage medical emergencies or urgent conditions that are designated as appropriate to be performed in the office setting.

Clinical contextPerformed during a face-to-face encounter when the provider determines diagnostic testing is necessary to establish diagnosis or select treatment.

Policy purposeLimits in-office testing to designated STAT codes to ensure appropriate setting and test quality.

Short Turnaround Time Lab Procedure

Short turnaround definitionLaboratory tests and services that are needed immediately in order to manage urgent or emergent medical situations.

Relation to STAT listShort turnaround (STAT) procedures are those designated on the policy's STAT laboratory procedure code list for in-office performance.

Use caseIntended for immediate management of urgent or emergent conditions during patient encounter.

Independent Laboratory

Independent LaboratoryA laboratory that is independent of an attending or consulting physician's office and of hospital.

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

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

Contracted Laboratory Provider

Contracted Laboratory ProviderA 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 expectationLaboratory procedures not included on the STAT list should be referred to a contracted lab provider when applicable.

Commercial arrangementContracted labs operate under an agreement with the health plan to provide services at negotiated rates.

OpenPayer

Payment Policy: Physician's Office Lab Testing

Coverage and Application

Code Lists and Coding Rules

Provider Billing and Compliance Actions

Definitions and Key Terms