BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA, INC.
IN-HOUSE LABORATORY LIST
UPDATED LIST EFFECTIVE June 1, 2013
CPT
DESCRIPTION
80047
BASIC METABOLIC PANEL (CALCIUM, IONIZED)
80048
BASIC METABOLIC PANEL
80051
ELECTROLYTE PANEL
80069
RENAL FUNCTION PANEL
80162
DIGOXIN
80170
GENTAMICIN
80198
THEOPHYLLINE
80200
TOBRAMYCIN
80202
VANCOMYCIN
81000
URINALYSIS, BY DIP STICK/TAB REAGENT FOR BILIRUBIN,GLUCOSE,
HEMOGLOBIN, …NON-AUTOMATED, WITH MICROSCOPY
81001
URINALYSIS, BY DIP STICK/REAGENT TAB AUTOMATED, WITH MICROSCOPY
81002
URINALYSIS, BY DIP STICK/TAB REAGENT NON-AUTOMATED WITHOUT
MICROSCOPY
81003
URINALYSIS, BY DIP STICK/TABLET REAGENT AUTOMATED, WITHOUT
MICROSCOPY
81005
URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE; EXCEPT IMMUNOASSAYS
81015
81025
URINALYSIS; MICROSCOPIC ONLY
82140
AMMONIA
82150
AMYLASE
82247
BILIRUBIN; TOTAL
82248
BILIRUBIN; DIRECT
82270
BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC); FECES, 1-3
SIMULTANEOUS
82272
BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC); QUALITATIVE,
FECES, SINGLE SPECIMEN
URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS
82274
BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY
IMMUNOASSAY,QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS
82565
CREATININE; BLOOD
82657
ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS OR TISSUE, NOT
ELSEWHERE SPECIFIED
82670
ESTRADIOL
82731
FETAL FIBRONECTIN, CERVICOVAGINAL SECRETIONS; SEMIQUANTITATIVE
82803
GASES, BLOOD, ANY COMBINATION OF PH,PCO2,PO2,CO2,HCO2 (INCLUDING
CALCULATED O2 SATURATION)
BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA, INC.
IN HOUSE LAB LIST
EFFECTIVE 06/01/13
*
1
CPT
DESCRIPTION
82805
GASES, BLOOD, ANY COMBINATION OF PH,PCO2,PO2,CO2,HCO2(INC
CALCULATED O2 SATURATION BY DIRECT MEASUREMENT, EXCEPT PULSE
OXIMETRY
82945
GLUCOSE; BODY FLUID OTHER THAN BLOOD
82947
GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP)
82948
GLUCOSE; BLOOD, REAGENT STRIP
83002
GONADOTROPHIN; LH
83014
HELICOBACTER PYLORI BREATH TEST ANALYSIS FOR UREASE ACTIVITY;
DRUG ADMINISTRATION
83036
HEMOGLOBIN; GLYCATED
83518
IMMUNOASSAY, FOR ANALYTE OTHER THAN ANTIBODY OR INFECTIOUS
AGENT ANTIGEN; SINGLE STEP METHOD
83661
FETAL LUNG MATURITY ASSESSMENT; (L/W) RATIO
83861
TEAR OSMOLARITY
84081
PHOSPHATIDYLGLYCEROL
84132
POTASSIUM; SERUM
84144
PROGESTERONE
84157
PROTEIN, OTHER SOURCE (eg SYNOVIAL FLUID, CEREBROSPINAL FLUID
84484
TROPONIN, QUANTITATIVE
84520
UREA NITROGEN (BUN); QUANTITATIVE
84703
GONADOTROPIN, CHORIONIC (hCG): QUALITATIVE
85002
BLEEDING TIME
85004
BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT
85007
BLOOD COUNT;BLOOD SMEAR MICROSCOPIC EXAMINATION WITH MANUAL
DIFFERENTIALWBC
85008
BLOOD COUNT; BLOOD SMEAR MICROSCOPIC EXAMINATION WITHOUT
MANUAL DIFFERENTIAL SBC COUNT
85009
BLOOD COUNT; MANUAL DIFFERENTIAL WBC COUNT, BUFFY COAT
85013
BLOOD COUNT;SPUN MICROHEMATOCRIT
85014
BLOOD COUNT; HEMATOCRIT (HCT)
85018
BLOOD COUNT; HEMOGLOBIN (HGB)
85025
BLOOD COUNT;COMPLETE (CBC),AUTOMATED (HGB, HCT, RBC, WBC AND
PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC
85027
BLOOD COUNT;COMPLETE (CBC), AUTOMATED (HGB,HCT,RBC,WBC AND
PLATELET COUNT)
85041
BLOOD COUNT; RED BLOOD CELL (RBC) AUTOMATED
85044
BLOOD COUNT; RETICULOCYTE, MANUAL
85045
BLOOD COUNT; RETICULOCYTE, AUTOMATED
BLOOD COUNT; LEUKOCYTE, AUTOMATED
85048
85097
BONE MARROW, SMEAR INTERPRETATION
85379
D-DIMER
85460
HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE;
DIFFERENTIAL
85461
HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE;
ROSETTE
85576
PLATELET; AGGREGATION (IN VITRO), EACH AGENT
85610
PROTHROMBIN TIME
BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA, INC.
IN HOUSE LAB LIST
EFFECTIVE 06/01/13
*
*
*
2
CPT
DESCRIPTION
85651
SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED
85652
SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED
THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD
85730
86077
BLOOD BANK PHYSICIAN SERVICES
86140
C-REACTIVE PROTEIN
86308
HETEROPHILE ANTIBODIES; SCREENING
86403
PARTICLE AGGLUTINATION; SCREEN, EACH ANTIBODY
86406
PARTICLE AGGLUTINATION; TITER, EACH ANTIBODY
86580
SKIN TEST; TUBERCULOSIS, PATCH OR INTRADERMAL
86756
RESPIRATORY SYNCYTIAL VIRUS
86759
ANTIBODY; ROTAVIRUS
86850
ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE
86880
ANTIHUMAN GLOBULIN TEST(COOMBS TEST) ;DIRECT, EACH ANTISERUM
86885
ANTIBODY GLOBULIN (COOMBS), INDIRECT
86900
BLOOD TYPING, ABO
86901
BLOOD TYPING; RH(D)
86920
COMPATIBILITY TEST; EACH UNIT; IMMEDIATE SPIN TECHNIQUE
86921
COMPATIBILITY TEST; EACH UNIT; INCUBATION TECHNIQUE
86922
COMPATIBILITY TEST; EACH UNIT; ANTIGLOBULIN TECHNIQUE
86923
COMPATIBILITY TEST; EACH UNIT, ELECTRONIC
87045
CULTURE, BACTERIAL; STOOL, AEROBIC WITH ISOLATION AND PRELIMINARY
EXAM
87110
CULTURE; CHLAMYDIA, ANY SOURCE
87164
DARKFIELD EXAMINATION, ANY SOURCE (EG., PENILE, VAGINAL, ORAL,SKIN);
IN-CLUDES
87205
SMEAR, PRIMARY SOURCE, WITH INTERPRETATION; GRAM STAIN OR
GIEMSA STAIN
87210
SMEAR PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECT
AGENTS
87220
TISSUE EXAMINATION FOR FUNGI OF SAMPLES FROM SKIN, HAIR, OR NAILS
FOR FUNGI OR ECTOPARASITE
87280
INFECTIOUS AGENT DETECTION BY DIRECT FLOURESCENT ANTIBODY
TECHNIQUE
87400
INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY
TECH,QUAL/SEMI-QUANTI
87803
C-DIFF TOXIN
87807
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT
OPTICAL OBSERVATION; INFLUENZA
INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT
OPTICAL OBSERVATION; RESPIRATORY SYNCYTIAL VIRUS
87880
INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL
OBSERVATION; STREPTOCOCCUS GRP A
87905
INFECTIOUS AGENT ENZYMATIC ACTIVITY OTHER THAN VIRUS (eg.
SIALIDASE ACTIVITY IN VAGINAL FLUID)
88172
CYTOPATHOLOGY; EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE
88173
CYTOPATHOLOGY; EVALUATION OF FINE NEEDLE ASPIRATE; FINAL
INTERPRETATATION & REPORT
88319
GROUP III FOR ENZYME CONSTITUENTS (WBC STAIN)
87804
BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA, INC.
IN HOUSE LAB LIST
EFFECTIVE 06/01/13
*
*
*
3
88738
HEMOGLOBIN (HgB), QUANTITATIVE, TRANSCUTANEOUS
89050
CELL COUNT, MISCELLANEOUS BODY FLUIDS (E.G. CSF, JOINT FLUID),
EXCEPT BLOOD
CPT
DESCRIPTION
89051
CELL COUNT, MISCELLANEOUS BODY FLUIDS (E.G. CSF, JOINT FLUID),
EXCEPT BLOOD WITH DIFFERENTIAL COUNT
89060
CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT
POLARIZING LENS ANALYSIS
89230
SWEAT COLLECTION BY IONTOPHORESIS
89250
CULTURE AND FERTILIZATION
89253
ASSISTED EMBRYO HATCHING, MICROTECHNIQUES
89254
OOCYTE ID FROM FOLLICULAR FLUID
89255
PREP OF EMBRYO FOR TRANSFER (ANY METHOD)
89258
CRYOPRESERVATION; EMBRYO (S)
89259
CRYOPRESERVATION; SPERM
89260
SPERM ISOLATION; SIMPLE PREP
89272
EXTENDED CULTURE OF OOCYTES/EMBRYOS 4-7 DAYS
89280
ASSISTED OOCYTE FERTILIZATION,MIC
89281
ASSISTED OOCYTE FERTILIZATION,MIC > 10 OOCYTES
89290
BIPOSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE
89291
BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE> 5 EMBRYOS
89300
SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM INCLUDING
HUHNER TEST (POST COITAL)
89310
89320
SEMEN ANALYSIS; MOTILITY & COUNT (NOT INCLUDING HUHNER TEST)
SEMEN ANALYSIS; COMPLETE (VOLUME, COUNT, MOTILITY AND
DIFFERENTIAL)
89321
SEMEN ANALYSIS, PRESENCE AND/OR MOTILITY OF SPERM
89322
SEMEN ANALYSIS; VOLUME, COUNT MOTILITY AND DIFFERENTIAL USING
STRICT MORPHOLOGIC CRITERIA (E.G. KRUGER)
89325
SPERM ANTIBODIES
89329
SPERM EVALUATION; HAMSTER PENETRATION
89330
SPERM EVALUATION;CERVICAL MUCUS PENETRATION TEST, WITH OR
WITHOUT SPINNBARKEIT TEST
89331
SEMEN EVALUATION: FOR RETROGRADE EJACULATION, URINE (SPERM
89335
CRYOPRESERVATION, REPRODUCTIVE TISSUE
89342
STORAGE, (PER YEAR); EMBRYO(S)
89343
STORAGE; SPERM/SEMEN
89346
STORAGE, (PER YEAR); OOCYTE(S)
89352
THAWING OF CRYOPRESERVED; EMBRYO(S)
89356
THAWING OF CRYOPRESERVED; OOCYTES
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
* = added 11/15/2012
BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA, INC.
IN HOUSE LAB LIST
EFFECTIVE 06/01/13
4