Peach State Provider Office Manual - Peach State Health Plan ...

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PROVIDER STAT LAB LISTEffective August 1, 2007, listed below are lab services that can be performed and reimbursed in anoffice setting. All other office based lab services must be submitted through our contractedlaboratory providers.CPTDescription80048 Basic Metabolic panel80051* Electrolyte Panel (must include Carbon Dioxide, Chloride, Potassium and Sodium) Effective :01/201081000Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein,specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy81001Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein,specific gravity, urobilinogen, any number of these constituents; automated, with microscopy81002 UA dip stick/tablet reagent; w/o micro non-auto81003 Automated, urine analysis without microscopy81005 Urinalysis; qualitative or semi-quantitative, except immunoassays81025 Urine pregnancy test, by visual color comparison methods82247 Bilirubin; Total82270 Blood, occult, by peroxidase activity (eg, guaiac); feces, 1-3 simultaneous determinations82272 Blood, occult, by peroxidase activity, single specimen82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations82465* Cholesterol, serum or whole blood, total Updated :03/201082565* Creatinine, Blood Effective :01/201082657Enzyme activity in blood cells, cultured cells or tissue, not elsewhere specified; nonradioactive substrate, eachspecimen Updated: 08/0982947 Glucose; quantitative, blood (except reagent strip)82948 Glucose; blood, reagent strip82570* Creatinine; other source82947* Glucose; quantitative, blood (except reagent strip) Effective: 01/201082950 Post glucose dose (includes glucose)82962 Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use83036 HGA1c83986 pH, body fluid, except blood Updated: 08/0984030 Phenylalanine (PKU), blood84520* Urea Nitrogen, Quantitative Effective: 01/201084702 Quantitative HCG84703 Gonadotropin, chorionic (HCG); qualitative85004 Blood count; automated differential wbc count85007 Blood count; manual differential WBC count (includes RBC morphology and platelet estimation)85013 Blood count; spun micro-hematocrit85014 Blood count; other than spun hematocrit85018 Blood count; hemaglobin85025Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBCcount85027 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)85032 Blood count; manual cell count (erythrocyte leukocyte or platelet) each85049 Blood count; platelet automated85610 Prothrombin time85651 Sedimentation rate, erythrocyte; non-automated85730 Thromboplastin time, partial (PTT); plasma or whole blood86140 C-reactive protein: Updated: 08/0986308 Heterophile antibodies; screening86403 Particle agglutination; screen, each antibody86580 Skin test; tuberculosis, intradermal86710 Antibody; influenza virus15Culture, bacterial; any other source except urine, blood or stool, with isolation and presumptive identification of87070isolates87081 Culture, presumptive, pathogenic Provider organisms, Services screening only87086 Culture, bacterial; quantitative 1-866-874-0633colony count, urine02/22/2011
83655 Lead Effective: 11/2010 Submission of 83655 requires CLIA Lab Certificate Code of (340) Chemistry-Toxicology87088 Culture, bacterial; with isolation and presumptive identification of isolates, urine87177 Ova and parasites, direct smears, concentration and identification87205Smear, primary source with interpretation, Gram or Giemsa stain for bacteria, fungi, or cell types87210 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps)8740087430Infectious agent antigen dection by enzyme immunoassay technique, qualitative or semiquantitative, multiplestep method; Influenza, A or B, eachInfectious agent antigen dection by enzyme immunoassay technique, qualitative or semiquantitative, multiplestep method; Streptococcus, group A87480 Infectious agent detection by nucleic acid (dna or rna); candida species, direct probe technique87510 Infectious agent detection by nucleic acid (dna or rna); gardnerella vaginalis, direct probe technique87660 Infectious agent detection by nucleic acid (DNA or RNA); trichomonas vaginalis, direct probe technique87800 Infectious agent detection by DNA or RNA multiple organisms, direct probe (s) technique87802 Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group B87803 Infectious agent antigen detection by immunoassay with direct optical observation; Clostridium difficile toxin A87804 Infectious agent antigen detection by immunoassay with direct optical observation; Influenza87807 Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus87880 Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A87808*Infectious agent antigen detection by immunoassay with direct optical obserbation; Trichomonas vaginalisUpdated: 03/201087905* Infectious agent enzymatic activity other than virus (eg., sialidase activity in vaginal fluid) Updated: 03/201089051* Cell count, miscellaneous body fluids, except blood with differential count Effective: 01/201089055 Leukocyte count fecal89190 Nasal smear for eosinophils Updated: 08/09G0306Complete CBC, automated (HGB, HCT, RBC, WBC, WITHOUT PLATELET COUNT) and automated WBCdifferential countG0307Q0111Complete (CBC), automated (HGB, HCT, RBC, WBC, without platelet count)Wet mounts, including preparation of vaginal, cervical or skin specimensNote:• All other laboratory services must be directed to our contracted laboratory providers.• Specialty lab services will continue to be submitted through Doctors Laboratory, Genzyme Genetics, FinanDermatopathology, Atlanta Dermatology and Pathology and Chatham County Board of Health Lab.July 1, 2007Revised:08/200903/201011/2010* Recently Added Codes16Provider Services1-866-874-063302/22/2011
Page 3 and 4: CHRONIC AND COMPLEX CONDITIONS.....
Page 5 and 6: Description of GeorgiaFamiliesGeorg
Page 7 and 8: have any questions about Peach Stat
Page 9 and 10: Provider ResponsibilitiesPRIMARY CA
Page 11 and 12: Planning for Healthy BabiesWaiver P
Page 13 and 14: Tubal Ligation(Sterilization)• St
Page 15: Additional InformationProviders see
Page 19 and 20: PROVIDER VISIT - WAITING TIMES• S
Page 21 and 22: Medical Management/Case Management1
Page 23 and 24: • Notification of all newborn del
Page 25 and 26: PROVIDER ASSISTANCE WITH PUBLIC HEA
Page 27 and 28: competency begins with self-awarene
Page 29 and 30: • Unresolved problems from previo
Page 31 and 32: • Member’s name, ID number• P
Page 33 and 34: Peach State may shorten the period
Page 35 and 36: Provider Services1-866-874-063302/2
Page 37 and 38: Notification is required to track i
Page 39 and 40: Members, a member’s representativ
Page 41 and 42: • HIV / AIDS• Children with Spe
Page 43 and 44: the member. The Peach State Medical
Page 45 and 46: Provider Services1-866-874-063302/2
Page 47 and 48: • A plan physician with privilege
Page 49 and 50: • In order to reimburse providers
Page 51 and 52: • Influence a member to choose on
Page 53 and 54: Covered Services andBenefits for Pe
Page 55 and 56: If you have any questions about the
Page 57 and 58: HEALTH CHECKGEORGIA HEALTH CHECK SE
Page 59 and 60: Health Check (EPSDT) Billing Requir
Page 61 and 62: Vaccine Codes must be billed with m
Page 63 and 64: Interperiodic Vision Only and Heari
Page 65 and 66: BLOOD LEAD SCREENINGPhysicians are
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General BillingInformation and Guid
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Peach State dental claims should be
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IMAGING REQUIREMENTSPeach State use
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PROCEDURES FOR FILING A CLAIM/ENCOU
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medical necessity. Peach State may
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Example: CPT 42820 submitted for a
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Procedure 99213 is submitted within
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Example: CPT 69436 billed with a 50
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BILLING CODESIt is important that p
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-Charge information and units• Se
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UB 04 CLAIM INSTRUCTIONSPeach State
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EMERGENCY DEPARTMENT HOSPITAL CLAIM
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Peach State Health PlanATTN: Peach
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Inquiry, Claims Adjustmentsand Prov
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selected, unless the plan and the p
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As accountable and fiscally respons
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CredentialingCREDENTIALING REQUIREM
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CREDENTIALING OF HEALTH DELIVERY OR
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Quality ImprovementTHE PEACH STATE
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PROVIDER REVIEWThe Peach State Qual
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AUTHORITY AND RESPONSIBILITYThe Pea
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Provider Services1-866-874-063302/2
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Member ServicesPeach State is commi
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• Income• Health Status• Arre
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• To keep all your appointments.
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• An Administrative Law Hearing d
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The staff often answers questions a
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PharmacyThe Peach State preferred d
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• Experimental drugs• Nutrition
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The member or provider, acting with
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Pharmacy ProgramPeach State Health
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Gender LimitsSome medications on th
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Cyclosporine, Digoxin, Disopyramide
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SPECIALTY MEDICATIONPRIOR AUTHORIZA
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Common Brand Name(s) Product Descri
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