Thursday, July 23, 2015

Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits


The CLIA regulations require a facility to be appropriately certified for each test performed. To ensure that Medicare and Medicaid only pay for laboratory tests in a facility with a valid, current Clinical Laboratory Improvement Amendments (CLIA) certificate, laboratory claims are currently edited at the CLIA certificate level.

The codes that are considered a laboratory test under CLIA change each year; providers need to know about the new codes that are both subject to and excluded from CLIA edits.

Change request 9035 informs Medicare contractors about numerous codes that were discontinued December 31 and added for 2015. Note: This does not include new codes for waived tests or provider-performed procedures.

Note: The code 89337 (frozen preservation of mature eggs) is new for 2015; it is excluded from CLIA edits and does not require a facility to have any CLIA certificate.

CLIA regulations require a facility to be appropriately certified for each test performed. To ensure that the Centers for Medicare & Medicaid Services (CMS) only pay for laboratory tests performed in certified facilities, each claim for a HCPCS code that is considered a CLIA laboratory test is currently edited at the CLIA certificate level.

The HCPCS codes that are considered a laboratory test under CLIA change each year, and your Medicare contractors need to be informed about the new HCPCS codes that are both subject to CLIA edits and excluded from CLIA edits.

Discontinued HCPCS Codes
The HCPCS codes listed in Table 1 below were discontinued on December 31, 2014.

Table 1: HCPCS Codes Discontinued on December 31, 2014
HCPCSCode Descriptor
G0417Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 21-40 specimens
G0418Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 41-60 specimens
G0419Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, >60 specimens
80100Drug screen, multiple drugs
80101Drug screen
80102Drug confirmation test
80103Tissue preparation for drug analysis
80104Drug screen, multiple drugs
80152Amitriptyline (antidepressant) level
80154Benzodiazepines level
80160Desipramine level
80166Assay of doxepin
80172Gold level
80174Imipramine level
80182Nortriptyline level
80196Salicylate (aspirin) level
80440Thyrotropin releasing hormone (TRH) (hypothalamus hormone) stimulation panel
82000Acetaldehyde blood test
82003Acetaminophen level
82055Alcohol (ethanol) level
82101Urine alkaloids level
82145Amphetamine or methamphetamine level
82205Barbiturates level
82520Cocaine (drug) level
82646Dihydrocodeinone (drug) measurement
82649Dihydromorphinone (drug) level
82651Dihydrotestosterone (DHT) level
82654Dimethadione (drug) level
82666Epiandrosterone (synthetic hormone) level
82690Ethchlorvynol (drug) level
82742Flurazepam (drug) level
82953Glucose (sugar) tolerance test
82975Glutamine (amino acid by product) level
82980Glutethimide (drug) level
83008Guanosine monophosphate (cellular chemical) level
83055Sulfhemoglobin (hemoglobin) analysis
83071Hemosiderin (hemoglobin breakdown product) level
83634Urine lactose (carbohydrate) analysis
83805Meprobamate (sedative) level
83840Methadone level
83858Methsuximide (drug) level
83866Mucopolysaccharides (protein) screening test
83887Nicotine level
83925Opiates (drug) measurement
84022Phenothiazine (drug) level
84127Stool porphyrins (metabolism substance) analysis
87001Animal inoculation, small animal with observation
87620Detection test for human papillomavirus (HPV)
87621Detection test for human papillomavirus (HPV)
87622Detection test for human papillomavirus (HPV)
88343Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear each additional separately identifiable antibody per slide (list separately in addition to code for primary procedure)
88349Assessment using electron microscopy

New HCPCS Codes for 2015
The HCPCS codes listed in Table 2 below are new for 2015 and are subject to CLIA edits. The list does not include new HCPCS codes for waived tests or provider-performed procedures. The HCPCS codes listed in Table 2 require a facility to have either a:
1.CLIA certificate of registration (certificate type code 9);
2.CLIA certificate of compliance (certificate type code 1); or
3.CLIA certificate of accreditation (certificate type code 3).

The following facilities are not permitted to be paid for these tests:
1.A facility without a valid, current, CLIA certificate;
2.A facility with a current CLIA certificate of waiver (certificate type code 2); or
3.A facility with a current CLIAcertificate for provider-performed microscopy procedures (certificate type code 4).

Note: The HCPCS code 89337 [Frozen preservation of mature eggs] is new for 2015, is excluded from CLIA edits and does not require a facility to have any CLIA certificate.


Table 2: New HCPCS Codes Subject to CLIA Edits for 2015
HCPCSCode Descriptor
G0464Colorectal cancer screening; stool-based dna and fecal occult hemoglobin (e.g., kras, ndrg4 and bmp3)
G6030Amitriptyline
G6031Benzodiazepines
G6032Desipramine
G6034Doxepin
G6035Gold
G6036Assay of imipramine
G6037Nortriptyline
G6038Salicylate
G6039Acetaminophen
G6040Alcohol (ethanol) any specimen except breath
G6041Alkaloids, urine, quantitative
G6042Amphetamine or methamphetamine
G6043Barbiturates, not elsewhere specified
G6044Cocaine or metabolite
G6045Dihydrocodeinone
G6046Dihydromorphinone
G6047Dihydrotestosterone
G6048Dimethadione
G6049Epiandrosterone
G6050Ethchlorvynol
G6051Flurazepam
G6052Meprobamate
G6053Methadone
G6054Methsuximide
G6055Nicotine
G6056Opiate(s), drug and metabolites, each procedure
G6057Phenothiazine
G6058Drug confirmation, each procedure
80163Digoxin level
80165Valproic acid level
80300-80304Drug screen
80320-80377Alcohols levels
81246Test for detecting genes associated with blood cancer
81288Test for detecting genes associated with colon cancer
81313Test for detecting genes associated with prostate cancer
81410Test for detecting genes associated with heart disease
81411Test for detecting genes associated with heart disease
81415Test for detecting genes associated with diseases
81416Test for detecting genes associated with disease
81417Reevaluation test for detecting genes associated with disease
81420Test for detecting genes associated with fetal disease
81425Test for detecting genes associated with disease
81426Test for detecting genes associated with disease
81427Reevaluation test for detecting genes associated with disease
81430Test for detecting genes causing hearing loss
81431Test for detecting genes causing hearing loss
81435Test for detecting genes associated with colon cancer
81436Test for detecting genes associated with colon cancer
81440Test for detecting genes associated with cancer of body organ
81445Test for detecting genes associated with cancer of body organ
81450Test for detecting genes associated with blood related cancer
81455Test for detecting genes associated with cancer
81460Test for detecting genes associated with disease
81465Test for detecting genes associated with disease
81470-81471Test for detecting genes associated with intellectual   disability
81519Test for detecting genes associated with breast cancer
87505-87507Detection test for digestive tract pathogen;
83006Test for detecting genes associated with growth stimulation
87623-87625Detection test for human papillomavirus (hpv)
87806Detection test for HIV1
88341Special stained specimen slides to examine tissue
88344Special stained specimen slides to examine tissue
88364Cell examination
88366Cell examination
88369Microscopic genetic examination manual
88373Microscopic genetic examination using computerassisted technology
88374Microscopic genetic examination using computerassisted technology
88377Microscopic genetic examination manual.

Note: Does not include new HCPCS codes for waived tests or provider-performed procedures.

On November 19, 2014, CMS released CR 8871 which mentioned that effective for services performed on or after June 2, 2014, the new HCPCS G0472, HCV screening, will be recognized as a covered service. G0472 is a code that:
•Is considered a test under CLIA;
•Is subject to CLIA edits; and
•Would require a facility to have either:
•A CLIA certificate of registration (certificate type code 9),
•A CLIA certificate of compliance (certificate type code 1), or


•A CLIA certificate of accreditation (certificate type code 3).

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