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First Priority Health Billable PCP Services
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Defines billable primary care physician (PCP) services, lists CPT/HCPCS codes for injectables, immunizations, administration, minor procedures, facility visit types, and billing rules applicable to First Priority Health providers.
Policy Summary
PayerHighmark Pennsylvania
PolicyFirst Priority Health Billable PCP Services
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJan 8, 2024
Next Review DateN/A
Key ActionObtain prior authorization from First Priority Health Pharmacy Department for specified immunizations when required.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
~200+CPT/HCPCS codes listed or referenced
~40Drugs & Biologicals J-codes enumerated
~9DEXA / bone density codes listed
Coverage and Billing Criteria
Billing and coverage rules
General coverage and billing constraints and rules for PCP billing under First Priority Health.
ALL of the following
Immunization rules
- Some immunizations require prior authorization from First Priority Health's Pharmacy Department.
- Immunizations that are required solely for travel or employment are not covered.
- Appropriate use of modifiers is required and practitioner medical record documentation must substantiate the codes selected and billed.
- Fees and codes are subject to change; benefit limits, exclusions, medical policy and procedure changes, and First Priority Health billing edits apply.
- Fee schedule rates represent the maximum payment and are reduced, as applicable, by member deductibles, coinsurance, copayments or payments from other third party payers.
- Codes within listed procedure ranges that are considered cosmetic are not eligible for payment.
- Manipulative therapy is an exclusion under basic coverage but may be available as a rider or under certain Point of Service products; verify member benefits.
Drugs & Biologicals — fee entries (partial)
Selected entries from the First Priority Health Drugs & Biologicals (J-code) fee schedule — partial list with dosing/unit notes where provided.
ANY of the following
- J0171 — Injection Adrenalin/Epinephrine (fee schedule entry).
- J0210 — Methylodopate HCL (fee schedule entry).
- J0280 — Aminophyllin; dosage up to 250 mg.
- J0290 — Ampicillin (fee schedule entry).
- J0295 — Ampicillin Sodium/Sulbactam Sodium; dosage 15 gm.
- J0558 — Injection, OnabotulinumtoxinA; unit dosing as listed.
- J0697 — Cefuroxime Sodium; dosage per 750 mg.
- J0882 — Darbepoetin alfa (for ESRD on dialysis); dosage 1 mcg.
- J0897 — Denosumab (Prolia); dosage listed as L mg in schedule.
- J2430 — Pamidronate Disodium; dosage per 30 mg.
- J3365 — Urokinase injection; 250,000 IU vial noted.
- J3370 — Vancomycin HCL; dosage up to 500 mg.
- J9015 — Aldesleukin; fee schedule per single use vial.
- J9293 — Mitoxantrone Hydrochloride; fee schedule per 5 mg.
Service and procedure code lists
Lists of CPT/HCPCS codes and brief descriptions for services, visits, diagnostics, labs and special services.
ANY of the following
SNF / Domiciliary / NF visit codes
- 99304-99310, 99315-99316, 99318 — Nursing facility initial, subsequent, discharge and annual assessment codes as listed.
- 99324-99328, 99334-99337 — Domiciliary visit codes (new and established patients) as listed.
Home visit codes
- 99347-99350 — Home visit codes for established patients.
Hospital/ED/Observation/Inpatient/Critical Care E&M
- 99217-99220, 99224-99226, 99231-99239 — Observation and inpatient E&M and discharge management codes.
- 99251-99255 — Inpatient consult codes.
- 99281-99285 — Emergency department visit E&M codes.
- 99291-99292, 99468-99480 — Critical care and related neonatal/pediatric critical care per-day codes.
Code Tables (CPT / HCPCS / J-codes)
Immunizations & Injectable Vaccines (CPT)CPTCovered
| 90281 | Immune globulin, intramuscular |
| 90283 | Immune globulin (IGIV), intravenous |
| 90291 | Cytomegalovirus immune globulin (CMV-IGIV), intramuscular |
| 90296 | Diphtheria antitoxin, equine |
| 90371 | Hepatitis B immune globulin (HBIG), intramuscular |
| 90375 | Rabies immune globulin (RIG), intramuscular/subcutaneous |
| 90376 | Rabies immune globulin, heat-treated (RIG-HT), intramuscular/subcutaneous |
| 90378 | Respiratory syncytial virus immune globulin (RSV-IGIV), intramuscular |
| 90384 | Immune globulin Rho(D) full dose, intramuscular |
| 90385 | Rho(D) immune globulin mini-dose, intramuscular |
1–10 of 71
1/8
Immunization Administration (CPT & Q-codes)mixedCovered
| 90460 | Immunization administration through 18 years with counseling, first vaccine/component |
| 90461 | Immunization administration through 18 years; each additional vaccine/component |
| 90471 | Immunization administration, one vaccine (adult) |
| 90472 | Immunization administration, each additional vaccine (adult) |
| 90473 | Immunization administration by intranasal or oral route |
| 90474 | Each additional vaccine by intranasal or oral route |
| Q2035 | Influenza vaccine, split virus, 3+ years, AFLURIA (product-specific) |
| Q2036 | Influenza vaccine, split virus, 3+ years, FLULAVAL (product-specific) |
| Q2037 | Influenza vaccine, split virus, 3+ years, FLUVIRIN (product-specific) |
| Q2038 | Influenza vaccine, split virus, 3+ years, product-specific (FLUVIRIN alt) |
1–10 of 12
1/2
Minor Dermatological Procedures (CPT ranges & examples)CPTCovered
| 10040-11101 | Biopsy and related minor skin procedure CPT range (use appropriate code for billed service) |
| 11300-13160 | Shaving/excision/repair procedures ranges for skin lesions (use appropriate CPT) |
| 17000-17999 | Destruction of premalignant or benign skin lesions (range) |
| 10060 | Incision & drainage of abscess, simple/single |
| 10120 | Incision & removal foreign body subq tissue |
| 11100 | Biopsy skin, subcutaneous &/or mucous membrane, 1 lesion |
| 11200 | Removal skin tags, multiple, any area, 15 or fewer |
| 11201 | Removal skin tags, multiple, any area, each additional 10 |
| 11300 | Shaving skin lesion trunk/arm/leg, diameter <=0.5 cm |
| 11302 | Shaving skin lesion trunk/arm/leg, diameter 1.1–2.0 cm |
1–10 of 12
1/2
SNF / Domiciliary / Nursing Facility Visits (CPT)CPTCovered
| 99304-99318 | Initial and subsequent nursing facility care, annual assessment and discharge (includes 99304-99316, 99318) |
| 99324-99337 | Domiciliary, rest home, custodial care services (new and established) including 99324-99337 |
| 99315 | Nursing facility discharge – 30 minutes or less |
| 99316 | Nursing facility discharge – more than 30 minutes |
| 99318 | Annual nursing facility assessment |
Bone Density (CPT / HCPCS)mixedCovered
| 77078 | CT bone density study, one or more sites |
| 77080 | DEXA bone density study, one or more sites; axial skeleton |
| 77081 | DEXA bone density study; appendicular skeleton (peripheral) |
| 77086 | Vertebral fracture assessment via DEXA |
| 76977 | Ultrasound bone density measurement, peripheral site(s) |
| 78350 | Bone density (single photon absorptiometry) |
| 78351 | Bone density (dual photon absorptiometry) |
| G0130 | SEXA bone density study, appendicular skeleton (peripheral) |
Misc Procedures (CPT)CPTCovered
| 20600 | Arthrocentesis, small joint |
| 20605 | Arthrocentesis, intermediate joint |
| 20610 | Arthrocentesis, major joint |
| 92552 | Pure tone audiometry |
| 92567 | Tympanometry |
| 97802 | Medical nutrition therapy; initial assessment and intervention, individual, each 15 minutes |
| 97803 | Medical nutrition therapy; re-assessment and intervention, individual, each 15 minutes |
Hospital / ED / Inpatient / Critical Care E&M (CPT)CPTCovered
| 99217-99239 | Observation, hospital discharge, inpatient initial and subsequent care codes (use appropriate code) |
| 99251-99255 | Initial inpatient consultations (when applicable) |
| 99281-99285 | Emergency department visit codes, levels 1–5 |
| 99291 | Critical care, first 30–74 minutes |
| 99292 | Each additional 30 minutes of critical care |
| 99468-99480 | Initial and subsequent inpatient neonatal and pediatric critical care per day and related codes |
Pathology & Laboratory (CPT)CPTCovered
| 80061 | Lipid panel |
| 82947 | Glucose; quantitative, blood |
| 83036 | Hemoglobin; glycosylated (HbA1c) |
| 83037 | Hemoglobin; glycosylated (A1C) by device cleared by FDA |
| 86580 | TB intradermal test (PPD) |
| 87070 | Culture, bacterial; other source except urine |
| 87081 | Culture presumptive pathogenic organism screening with colony estimate |
| 87430 | Infectious agent detection: Streptococcus group A |
| 87804 | Infectious agent detection: Influenza |
| 87880 | Infectious agent detection: Streptococcus group A (alternate) |
Drugs & Biologicals (HCPCS J-codes) — selected rangeHCPCSCovered
| J0171 | Epinephrine injection |
| J0210 | Methyldopa HCL |
| J0280 | Aminophylline |
| J0290 | Ampicillin |
| J0295 | Ampicillin/Sulbactam |
| J0558 | OnabotulinumtoxinA (per unit) |
| J0882 | Darbepoetin alfa (for ESRD on dialysis) |
| J0885 | Epoetin alfa (non‑ESRD use) |
| J0897 | Denosumab (Prolia) |
| J1460 | Gamma globulin, intramuscular |
1–10 of 20
1/2
Provider Billing Actions and Alerts
Billing Rule
SNF / Personal Care Home Visits (CPT)
SNF and Personal Care Home Visits — provider must code and document visits using the appropriate nursing facility and domiciliary codes listed below. Ensure documentation supports level of care, complexity, time and discharge/annual assessment services where billed.
Documentation Required
DEXA and Bone Density Codes
DEXA and bone density studies — use the correct CPT/HCPCS code for the modality and site measured. Documentation should include site(s) scanned and indication for testing.
- 77078 - CT bone density, one or more sites
- 77080 - DEXA, axial skeleton (hip/pelvis/spine)
- 77081 - DEXA, appendicular (peripheral)
- 77086 - Vertebral fracture assessment via DXA
- 76977 - Ultrasound bone density measurement, peripheral
- 78350 - Single photon absorptiometry, one or more sites
- 78351 - Dual photon absorptiometry, one or more sites
- G0130 - Single energy X-ray absorptiometry (SEXA), peripheral
Documentation Required
Hospital / ED / Critical Care Codes
Hospital observation, inpatient, ED and critical care services must be billed with the correct E/M or critical care codes; documentation must support severity, time and decision making level claimed. Use observation discharge, initial and subsequent inpatient, ED visit and critical care codes as applicable.
Billing Rule
Pathology and Lab Codes
Pathology and laboratory tests — order and bill using the appropriate CPT/HCPCS codes. Ensure documentation supports test necessity and any reflex testing performed.
- 80061 - Lipid panel
- 81002 - Urinalysis (non-automated)
- 82947 - Glucose quantitative
- 83036 - Hemoglobin A1c
- 83037 - A1c by FDA-cleared device
- 86580 - TB intradermal test
- 87070 - Culture, bacterial (except urine, blood, stool)
- 87081 - Culture with colony count estimate
- 87430 - Infectious agent detection, Group A Streptococcus
- 87804 - Influenza rapid test
- 87880 - Streptococcus Group A rapid test
Note
Drugs & Biologicals (J‑codes) — partial list
Drugs & Biologicals (selected J‑codes) — when billing injectable drugs and biologics ensure J‑codes, dosages and units match documentation and fee schedule. This is a partial list; reference the full fee schedule for additional J‑codes and dose/unit requirements.
- J0171 - Injection, epinephrine
- J0210 - Methyldopate HCl
- J0280 - Aminophylline (up to 250 mg)
- J0290 - Ampicillin
- J0295 - Ampicillin/Sulbactam (15 gm)
- J0300 - Amobarbital
- J0330 - Succinylcholine (up to 20 mg)
- J0360 - Hydralazine (up to 20 mg)
- J0380 - Metaraminol (up to 10 mg)
- J0390 - Chloroquine
- J0461 - Atropine (0.01 mg)
- J0470 - Dimercaprol (up to 100 mg)
- J0558 - OnabotulinumtoxinA (per unit)
- J0585 - Botulinum toxin type A (per unit)
- J0630 - Calcitonin-salmon (up to 400 units)
- J0640 - Leucovorin calcium (per 50 mg)
- J0694 - Cefoxitin sodium
- J0696 - Ceftriaxone sodium
- J0697 - Cefuroxime sodium (per 750 mg)
- J0702 - Betamethasone acetate/sodium phosphate (per 3 mg)
- J0743 - Cilastatin/Imipenem injection
- J0780 - Prochlorperazine (up to 10 mg)
- J0882 - Darbepoetin alfa (ESRD on dialysis)
- J0885 - Epoetin alfa (non-ESRD)
- J0897 - Denosumab (Prolia)
- J1020 - Methylprednisolone acetate (20 mg)
- J1030 - Methylprednisolone acetate (40 mg)
- J1040 - Methylprednisolone acetate (80 mg)
- J1442 - Filgrastim (per microgram)
- J2430 - Pamidronate disodium (per 30 mg)
- J2790 - Rho(D) immune globulin, human
Definitions and Fee Schedule Notes
Fee schedule / payment limits
DefinitionFee schedule rates represent the maximum payment to the practitioner and shall be reduced, as applicable, for any member deductibles, coinsurance, copayments or payments from other third‑party payers.
Relation to member cost‑sharingPayments are subject to member financial responsibility (deductible, coinsurance, copayment) and will reduce the amount First Priority Health pays under the fee schedule.
Effect of other payersAmounts payable by other third‑party payers will reduce the fee schedule payment to the practitioner.
Contractual changesFees and codes are subject to change in accordance with contractual provisions, billing edits, benefit limits, exclusions and medical policy changes.
Documentation requirementAppropriate use of modifiers and practitioner's medical record documentation must substantiate billed codes and payments.
Manipulative Therapy coverage status
Coverage statusManipulative Therapy is an exclusion under basic First Priority Health coverage but may be available as a rider.
Point of Service productsCertain Point of Service products offer Manipulative Therapy as a benefit; verify member coverage with Member Services.
Member verificationContact Member Services at 1‑800‑822‑8752 to determine if the member has Manipulative Therapy benefit.
Representative CPT codes98925 (OMT 1–2 regions), 98926 (3–4 regions), 98927 (5–6 regions).
DEXA
TermDEXA / bone density studies
Included codes77078, 77080, 77081, 77086, 76977, 78350, 78351, G0130
Code descriptions77080/77081 = Dual energy X‑ray absorptiometry (DEXA) bone density study (axial and appendicular sites); 77086 = Vertebral Fracture Assessment via DXA.
Alternative methods76977 = Ultrasound bone density measurement (peripheral); 78350/78351 = single/dual photon absorptiometry studies.
Hospital/ED/Critical Care E&M
DefinitionEvaluation and management (E&M) codes for hospital observation, inpatient, emergency department and critical care services.
Included code rangesObservation/inpatient/consult: 99217–99239, 99251–99255; Emergency Dept: 99281–99285; Critical care: 99291–99292; Pediatric/neonatal critical care: 99468–99480.
Examples99217 = Observation Care Discharge Day Management; 99285 = ED visit E&M – high severity; 99291 = Critical Care, first 30–74 minutes.
Scope noteList includes initial, subsequent, discharge, consult, ED and critical care daily codes with varying severity/time descriptors.
Policy Summary
PayerHighmark Pennsylvania
PolicyFirst Priority Health Billable PCP Services
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJan 8, 2024
Next Review DateN/A
Key ActionObtain prior authorization from First Priority Health Pharmacy Department for specified immunizations when required.
SourceLink
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