2004 CPT-4, HCPCS Additional Policy Changes
November 1, 2004The 2004 updates to the Current Procedural Terminology – 4th Edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) National Level II and Local Level III codes are effective for Medi-Cal for dates of service on or after October 18, 2004 and policies were published in the September Medi-Cal Update. Additional policy changes are highlighted below.
Radiology Codes Requiring Split Bill Modifiers
HCPCS radiopharmaceutical codes A9525 and A9528 – A9532 are 100 percent professional and must be billed with modifiers -26 or -ZS. The codes are billable by hospitals or radiologists.
Maximum Reimbursement: Code Combinations: Only one code in the combination of CPT-4 codes 70250 v. 70260 will be reimbursed if billed for the same date of service, same provider.
Prenatal Cystic Fibrosis Screening
Effective for dates of service on or after November 01, 2004, providers may bill for up to a maximum quantity of 25 combination laboratory tests listed below, which screen for the presence of a mutant gene likely to contribute to a pregnant woman giving birth to a baby with cystic fibrosis.
| CPT-4 Code | Description |
| 83890 | Molecular diagnostics; molecular isolation or extraction |
| 83891 | isolation or extraction of highly purified nucleic acid |
| 83892 | enzymatic digestion |
| 83893 | dot/slot blot production |
| 83894 | separation by gel electrophoresis (e.g. agarose, polyacrylamide) |
| 83896 | nucleic acid probe, each |
| 83897 | nucleic acid transfer (e.g. Southern, Northern) |
| 83898 | amplification of patient nucleic acid (e.g. PCR, LCR), single primer pair, each primer pair |
| 83901 | amplification of patient nucleic acid, multiplex, and each multiplex reaction |
| 83904 | mutation identification by sequencing, single segment, each segment |
Note: CPT-4 code 83912 (interpretation and report) is still limited to one per day.
In addition, the following conditions apply:
- Providers must document in the diagnosis field of the claim ICD-9 diagnosis code V26.3 genetic counseling and testing.
- Fetal testing is reimbursable using the recipient’s Medi-Cal identification number if “fetal specimen” and medical justification is documented in the Remarks area/Reserve For Local Use field (Box 19). Failure to document these tests will result in denial of the claim.
- Cystic fibrosis screening is reimbursable for the father only if he is a Medi-Cal recipient. Providers must document in the Remarks area/Reserved For Local Use field (Box 19), “patient screen positive/partner sample his recipient number” and ICD-9 code V26.3 or the claim will be denied.
- Cystic fibrosis screening is an once-in-a-lifetime procedure.
- The maximum reimbursement for any combination of the above codes is $180.
The updated information is reflected on manual replacement pages path molec 1 and 2. (Part 2).