NEW YORK STATE MEDICAID PROGRAM FEE-FOR-SERVICE

NEW YORK STATE

MEDICAID PROGRAM

FEE-FOR-SERVICE LABORATORY

PROCEDURE CODES AND COVERAGE

GUIDELINES MANUAL

NYS Medicaid FFS Laboratory Procedure Codes and Coverage Guidelines Manual

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Table of Contents

GENERAL INFORMATION AND RULES ..................................................................................................................................... 3

ORGAN OR DISEASE ORIENTED PANELS ............................................................................................................................... 13

THERAPEUTIC DRUG ASSAYS ................................................................................................................................................ 14

EVOCATIVE/SUPPRESSION TESTING ..................................................................................................................................... 16

URINALYSIS ............................................................................................................................................................................ 17

MOLECULAR PATHOLOGY ..................................................................................................................................................... 17

MULTIANALYTE ASSAYS WITH ALGORITHMIC ANALYSES ..................................................................................................... 25

CHEMISTRY ............................................................................................................................................................................ 25

HEMATOLOGY and COAGULATION ....................................................................................................................................... 34

IMMUNOLOGY ...................................................................................................................................................................... 36

TRANSFUSION MEDICINE ...................................................................................................................................................... 40

MICROBIOLOGY ..................................................................................................................................................................... 40

CYTOPATHOLOGY .................................................................................................................................................................. 46

CYTOGENETIC STUDIES ......................................................................................................................................................... 47

SURGICAL PATHOLOGY ......................................................................................................................................................... 48

OTHER PROCEDURES............................................................................................................................................................. 50

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GENERAL INFORMATION AND RULES

1. The fees in the Laboratory Fee Schedule apply to clinical laboratory tests selected from Physician's

Current Procedural Terminology (CPT), Professional Edition, 2016 or the Healthcare Common

Procedure Coding System (HCPCS), Professional Edition, 2016. Reimbursement is limited to

indicated uses of procedures that are FDA approved for in vitro diagnostic use or, are recognized as

generally acceptable by the New York State Department of Health. NYS Medicaid Updates for the

most current coverage policies can be accessed at the following link:

http://www.health.ny.gov/health_care/medicaid/program/update/main.htm

2. The fees include the services of all licensed professionals required by certification in the

performance of the test.

3. The fees include all costs related to specimen testing, including collection, storage and transport of

specimens, in addition to performance and reporting of results. Unreported instrument controls are

not separately reimbursable. "By Report" (BR), as indicated in the Fee Schedule, reimbursement

requires a statement indicating the need for the service, the type of test performed, test results, the

number and source of the specimen(s) and documentation of the laboratory's usual and customary

charge to the general public for the service.

4. The fees are for quantitative analyses, unless otherwise specified. Mathematical calculations

(e.g., calculation of A/G ratio, ionized calcium, free thyroxine index (T 7) or osmolality) are not

reimbursable.

5A. Therapeutic drug monitoring is reimbursable when quantitative determination of blood

concentration is clinically relevant as a part of a regimen designed to attain and sustain therapeutic

effect by maintenance of blood level within a defined range. The intensity and probability of

therapeutic or toxic effect must quantitatively correlate with blood concentration. In addition, one or

more of the following criteria must be satisfied:

(1) there is a narrow range between those concentrations giving the desired response and those

producing toxicity, (2) readily assessed alternative endpoints (e.g., prothrombin time for oral

anticoagulants) are lacking or (3) there is large inter individual variability in the absorption and

disposition of the drug. Therapeutic monitoring is a covered service only when performed on

specimens of blood. Use the drug specific codes 80150 through 80203. Code 80299 is to be used

only for drugs, which meet the criteria for therapeutic monitoring, outlined above and are not listed by

individual code. Codes 80299 is billable "By Report" and the drug(s) must be specified in the

procedure description field on the Claim Form. Peak and trough (or predose and postdose) analyses,

when clinically indicated (e.g., aminoglycosides), are reimbursable as two procedures.

5B. NYS Medicaid drug testing policy follows a two-step testing process/structure that consists of the use

of screening (presumptive) tests then confirmatory (quantitative) tests. Presumptive drug class screening

tests using Common Procedural Terminology (CPT) codes "80305", "80306" or "80307" are the first step

in the process. Only substances that return positive results or are inconclusive on screening tests

(presumptive) or results on screening tests that are inconsistent with clinical presentations are

reimbursable for confirmation (quantitative) testing using CPT codes "80321" through "80377" listed on

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the fee schedule. Definitive or direct confirmation tests using CPT code "G0480" are only reimbursable

when no screening methods for the substances are available.

Tests for a drug(s) or drug classes must be ordered by the provider and should be considered for

inclusion based on the patient´s medical history and/or current clinical presentation. Broad panel tests,

reflex tests initiated by the lab, and routine standing orders are not reimbursable. Medical records must

support the need for each drug or drug class being tested and must be kept on file, in accordance with

regulations, for audit purposes.

https://www.health.ny.gov/health_care/medicaid/program/update/2021/no10_2021-08.htm#drugtest

6A. Certain laboratory procedures are often performed, either manually or on automated equipment,

in combination with each other. For purposes of reimbursement, when a code defines a specific

combination of procedures performed on a date of service, it is appropriate to utilize that unique code.

6B. When procedures for Vitamin B12 (82607) and Folate (82746 or 82747) are performed in

combination, the maximum reimbursable fee for code 82746 or 82747 is $6.25. When a procedure for

Ferritin (82728) is performed in combination with Vitamin B12 or Folate, or any of the Organ or

Disease Oriented Panels (80048-80076), or any of the individual chemistry analyte codes listed in the

fee schedule (see Rule 6A), the maximum reimbursable fee for 82728 is $5.70.

6C. When two or more Hepatitis B tests are performed in combination, reimbursement will be reduced

by 50% for each test after the first. See also Rule 16. When Hepatitis A, C or D tests (codes 86692,

86708, 86709, 86803 or 87380) are performed in combination with each other or with any Hepatitis B

test, the maximum reimbursable fee per Hepatitis A, C or D test is $5.00. When multiple procedures

for antigen or antibody to two or more infectious agents (codes 86602-86689 and 86698-86703 or

86710-86793) are performed in combination, reimbursement is limited to the greater fee plus 50% of

the lesser fee(s). The fee for code 86701 Antibody HIV-1 includes reimbursement for up to three

screen assays of a single specimen. Use code 87390 for P24 HIV antigen.

7A. For purposes of reimbursement based on the Laboratory Fee Schedule, a complete blood count

(CBC) includes a hematocrit, hemoglobin determination, RBC count, RBC indices, WBC count and a

platelet count. See code 85027. For a CBC with an automated differential WBC count, use code

85025. Code 85060 requires interpretation by physician and written report.

7B. Codes for CBC individual components (85013, 85014, 85018, 85048 and 85049) may not be

billed in conjunction with procedure codes including a CBC (85025 and 85027). The code for

automated differential WBC count (85004) may not be billed in conjunction with codes 85025 and

85027.

8. For purposes of reimbursement, codes 86850 and 86905 represent examples of procedures

considered to be integral parts of outpatient transfusion and hemodialysis services. No separate

reimbursement will be allowed.

9. For pregnancy detection and where the reported test result is qualitative or semi-quantitative, use

code 81025 or 84703. Code 84702 is reimbursable for a quantitative HCG value reported for a

diagnostic use (e.g., monitoring post-surgical growth of germ cell neoplasm where quantitative HCG

is relative to growth). Code 84702 is not reimbursable for a routine screen for pregnancy.

10. Appropriate billing of antibody and antigen procedures is as follows:

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• For antibody or antigen as specific markers of infectious disease, use the most specific

code corresponding to the organism’s name (e.g., 86618 Antibody; Borrelia burgdorferi) or

the disease name (e.g., 87340 Hepatitis B surface antigen).

• For an infectious agent antibody or antigen not listed by name, use the "By Report" code

for the type of organism (e.g., 86609 Antibody; bacterium not elsewhere specified or the

analytical method, e.g., 87299 Infectious agent antigen detection by immunofluorescent

technique; not otherwise specified, each organism). Document the name of the organism,

and, if applicable, the immunoglobulin subclass(es), on the Claim Form (See Rule 3).

• For antibody other than to infectious agent(s) (e.g., autoantibodies) use the most specific

code corresponding to the analyte (e.g., 86376 Microsomal antibody (e.g. thyroid or liver-

kidney, each)).

• For non-infectious agent antibody or antigen NOT listed by analyte, use the most specific

code for the method used (e.g., 86255 Fluorescent noninfectious agent antibody; screen

each antibody); when billing "By Report", the name of the analyte must be documented on

the Claim Form (See Rule 3).

• Multiple tests to detect (1) antibodies to organisms/analytes classified more precisely than

the specificity allowed by available codes, (2) antibodies in paired specimens (acute vs.

convalescent), or (3) antibodies of different immunoglobulin subclasses, are reimbursable

as separate procedures; multiple units of a code (e.g., two units of 86658 for Coxsackie A

and B species of enterovirus) may be claimed when analyses yield separately reported

results for each subclassification, specimen or Ig subclass.

11. Organ or Disease Orientated Panel codes. Effective July 1, 2000, the panel codes 80047, 80048,

80051, 80053, 80061, 80069 and 80076 should be used to bill designated combinations of tests

regardless of whether the tests are ordered and/or performed individually, as a panel, or as multiple

panels at different times. If 2 or more panel codes with overlapping component tests, (i.e., 80047,

80048, 80051, 80053, 80076) are billed, the lab is not entitled to reimbursement for the duplicate

tests. If one or more of the codes for chemistry tests where this rule applies are billed in combination

with another and/or a panel code, total payment due for those chemistry tests is limited as follows: up

to 2=$5.03, 3-6=$6.04, 7-9=$7.25, 10-12=$9.09, 13-16=$10.00, 17-18=$11.00, 19 or more=$12.00.

12. Cytogenetic studies codes 88245, 88267 and 88269 must be billed in combination with code

88280 to report a 2-karyotype chromosome analysis as described in the quality control standards for

cytogenetic licensure.

13. Reimbursement for immune electrophoresis includes payment for the electrophoretic separation

and quantitation. Therefore, no separate reimbursement for code 84165will be allowed when code(s)

86320-86325 are billed.

14.A. Genetic Testing General Guidance

The molecular pathology codes (81400 through 81408, 81479 and 84999) are reimbursable for DNA

based genetic testing not specifically listed in the fee schedule. All molecular pathology codes (81200

through 81408 and 81479) may be performed as (1) a family study of up to six individuals to

determine the genetic carrier/disease status of an individual patient or a fetus as part of a

comprehensive program of genetic counseling and when indicated by familial medical history or

adjunctive prenatal testing OR (2) an individual study by diagnostic deletion analysis of a patient

affected by a genetic disorder. DNA based testing defined under State licensure as investigational for

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a certain disease is not reimbursable. Codes 81400 through 81408, 81479 and 84999 are not

reimbursable for non-genetic applications such as microbial detection or quantification or testing for

acquired changes in genetic material (e.g., T or B cell markers, immunoglobulin heavy or light chain

rearrangements associated with malignancy). Reimbursement for these codes should be submitted

according to the “By Report” instructions in Rule 3.

B. Genetic Testing Specific Guidance

Please note: There has been coding changes for some of the genetic testing policies. Periodically

check the Medicaid Update Website at the link below for the most recent information.

https://www.health.ny.gov/health_care/medicaid/program/update/main.htm

Whole Exome Sequencing (WES) – WES should be billed using CPT codes 81415 and 81417. NYS

Medicaid will reimburse, and consider medically necessary, WES when the member meets the

following criteria:

Members 18 years of age and younger are eligible for testing for the evaluation of unexplained

neurodevelopmental, neurological, or congenital disorders when all the following criteria are met:

• Clinical presentation and history of the patient suggests a genetic etiology;

• Clinical presentation does not fit a well-defined syndrome;

• Clinical presentation cannot be attributed to an environmental exposure, injury, infection, or

other nongenetic etiology;

• Prior genetic testing for specific disorders has failed to yield a diagnosis;

• No additional genetic tests are being ordered concurrently;

• The individual has been evaluated and the test ordered by a physician specializing in clinical

genetics or with extensive experience evaluating patients with suspected genetic syndromes;

and

• Testing is expected to inform management decisions and/or avoid additional diagnostic tests,

which may be unnecessary, expensive, and/or uncomfortable.

WES is the analysis of regions of chromosomal DNA that code for proteins to identify clinically

significant mutations. WES will be covered once in a lifetime for NYS Medicaid FFS members and

MMC enrollees 18 years of age and younger. However, consideration may be given to members 19

years of age and older if they meet the criteria above and would have benefited from the results of

this analysis had it been available when they were younger. WES for fetal screening or diagnosis will

not be covered.

Whole genome sequencing (WGS) looks at both the coding and noncoding regions of chromosomal

DNA. WGS will not be covered by NYS Medicaid.

The decision to test should be consistent with the current evidence supporting clinically meaningful

associations between findings from genetic sequencing and the phenotype under investigation.

Expertise in clinical genetics allows for accurate evaluation of patients, determination of whether

targeted testing would produce a more cost-effective and higher yield than WES, and interpretation of

results for a specific patient.

Documentation should support the benefit of WES, the failure of prior genetic testing to yield a

relevant result, and how WES test results may preclude the need for more costly and/or invasive

procedures, follow-up, or screening. Information on written informed consent may be found in Section

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79-I, Article 7, of NYS Civil Rights Law, on the New York State Senate web page, available at

https://www.nysenate.gov/legislation/laws/CVR/79-L.

Fragile X - Prenatal carrier testing for fragile X syndrome should be billed using CPT codes 81171,

81172, 81243 and 81244. To verify that a patient meets NYS Medicaid criteria for testing, please visit

the August 2014 Medicaid Update at the following link:

http://www.health.ny.gov/health_care/medicaid/program/update/2014/2014-08.htm

Diagnostic testing of children for fragile X syndrome continues to be covered if medically necessary.

Spinal Muscular Atrophy (SMA) - Prenatal carrier testing for SMA should be billed using CPT codes

81329, 81336 and 81337. To verify that a patient meets NYS Medicaid criteria for testing, please visit

the October 2023 Medicaid Update at the following link:

https://www.health.ny.gov/health_care/medicaid/program/update/2023/no15_2023-10.htm .

Carrier screening for SMA of the male partner of a pregnancy will be covered if the pregnant female is

found to be a carrier. Diagnostic testing of individuals for SMA continues to be covered if medically

necessary.

Trisomy Screening - Non-invasive prenatal screening for trisomy 13, 18 and 21 using cell-free fetal

DNA for high-risk singleton pregnancies should be billed using CPT code 81507 or 81420. To verify

that a patient meets NYS Medicaid criteria for testing, please visit the October 2014 Medicaid Update

at the following link: http://www.health.ny.gov/health_care/medicaid/program/update/2014/2014-

10.htm. Diagnostic testing (e.g., cytogenetic analysis or molecular genetic testing) for suspected

aneuploidies continues to be covered if medically necessary. Micro-deletion testing in conjunction

with noninvasive trisomy testing is not reimbursable.

BRCA - Testing for mutations in the BRCA1 and BRCA2 genes of individuals at high risk for

hereditary breast and ovarian cancer (HBOC) should be billed using the appropriate code(s): 81162,

81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, or 81217 if the patient meets NYS

Medicaid criteria. Please view the current guidelines which were published in the October 2015

Medicaid Update at the following link:

http://www.health.ny.gov/health_care/medicaid/program/update/2015/2015-10.htm

BRCA1 and BRCA2 mutation testing in conjunction with BRCA Large Rearrangement Test

(BART) must be billed using CPT code 81162 effective 4/01/2016.

BRCA Large Rearrangement Test (BART) – BART tests for large rearrangement mutations in

BRCA genes. If a Medicaid enrollee previously had testing for BRCA1 and BRCA2 genes with

negative test results, and Bart testing was not performed, the enrollee may have BART only testing

(represented by CPT 81164). The addition of BART testing must be considered medically necessary.

For a Medicaid enrollee where BRCA1 and BRCA2 testing is being ordered for the first time, BART is

performed as a reflex test if the BRCA1 and BRCA2 test results are negative. When performing tests

for BRCA1 and BRCA2 plus BART, CPT Code 81162 must be billed.

Oncotype DX®, EndoPredict®, Prosigna®, Breast Cancer Index®, and MammaPrint® for

Breast Cancer - Oncology (breast), mRNA, gene expression profile testing to aid practitioners in

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determining the appropriate use of chemotherapy should be billed using CPT code 81519 for

Oncotype DX®, CPT code 81522 for EndoPredict®, CPT code 81520 for Prosigna®, CPT code

81518 for Breast Cancer Index®, or CPT 81521 for MammaPrint®. Only one prognostic breast

cancer assay is reimbursable per histologically distinct tumor. To verify that a patient meets NYS

Medicaid criteria for testing, please visit the December 2023 Medicaid Update at the following link:

https://www.health.ny.gov/health_care/medicaid/program/update/2023/no17_2023-12.htm.

Lynch Syndrome - Testing for mutations in MLH1 and MSH2 genes of individuals at high risk for

Lynch Syndrome and meeting NYS Medicaid criteria should be billed using the following codes:

81292 and 81295. Known mutation or reflex testing may be reimbursable using one the following

codes: 81288, 81294, 81297, 81298, 81300, 81317 and 81319. Testing guidelines and criteria for

Lynch Syndrome testing can be found in the December 2023 Medicaid Update at the following link:

https://www.health.ny.gov/health_care/medicaid/program/update/2023/no17_2023-12.htm.

clonoSEQ

- clonoSEQ

, an FDA-cleared in vitro diagnostic (IVD) test, should be billed using

CPT 81479. This test is provided to detect measurable residual disease (MRD) in bone marrow

from patients with multiple myeloma or B-cell acute lymphoblastic leukemia (B-ALL) and blood or

bone marrow from patients with chronic lymphocytic leukemia (CLL).

C. Pharmacogenetic Testing

CYP2D6 - Testing for CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) gene

analysis, common variants should be billed using CPT code 81226. NYS Medicaid considers

genotyping, once in a lifetime, for CYP2D6 polymorphisms medically necessary to determine drug

therapy for the following:

• Patients diagnosed with Huntington’s disease requiring doses of Xenazine® (tetrabenzine) greater

than 50 mg per day.

• Patients diagnosed with Gaucher disease type 1 requiring Cerdelga® (eliglustat).

At this time, pharmacogenetic testing of CYP2D6 for any purpose other than those specified above is

not reimbursable.

CYP2D9 - Testing for CYP2D9 (cytochrome P450, family 2, subfamily C, polypeptide 9) gene

analysis, common variants (e.g., *2,*3,*5,*6) should be billed using CPT code 81227. NYS Medicaid

considers genotyping, once in a lifetime, for CYP2D9 medically necessary to determine eligibility for

MAYZENT® (siponimod) drug therapy.

DMD - Testing of the DMD (dystrophin) (e.g., Duchene/Becker muscular dystrophy) gene should be

billed using CPT code 81161. NYS Medicaid considers testing, once in a lifetime, medically

necessary to determine eligibility for Exondys 51® (eteplirsen) drug therapy.

BCR/ABL1 - Testing for BCR/ABL1 (t(9;22)) translocation analysis should be billed using CPT code

81170. NYS Medicaid considers BCR/ABL1 testing medically necessary to determine drug therapy

for the following:

• Patients diagnosed with chronic myelogenous leukemia (CML) or Acute Lymphoblastic Leukemia

(ALL) that have been prescribed Gleevec® (imatinib), Sprycel® (dasatinib), Tasigna® (nilotinib),

Bosulif® (bosutinib) or Iclusig® (ponatinib) and one or more of the following:

o have an inadequate initial response to tyrosine kinase inhibitor (TKI) therapy

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o exhibit a loss of response (defined as a hematologic or cytogenetic relapse)

o 1-log increase in BCR-ABL1 transcript levels and loss of major molecular response (MMR)

o have disease progression to accelerated or blast phase

PDGFRA - Testing for platelet-derived growth factor receptor, alpha polypeptide (PDGFRA) gene

analysis should be billed using CPT code 81314. NYS Medicaid considers PDGFRA testing medically

necessary, once in a lifetime, when used to determine drug therapy for the treatment of chronic

myeloid leukemia such as Imatinib (Gleevec).

EGFR - Testing for neuroblastoma RAS viral [v-ras] oncogene homolog gene analysis should be

billed using CPT code 81311. NYS Medicaid considers EGFR testing medically necessary, once in a

lifetime, when used to determine effective drug therapy for medications such as cebtuximab (Erbitux)

that treat certain cancers (e.g., lung, colorectal, head and neck) thought to be associated with this

genetic mutation.

15. Code 82105, 82106, 82378, 83950, 83951, 84066, 84153, 84154, 84702 or 86316 is

reimbursable for an oncofetal antigen (tumor marker) procedure used as an adjunctive test with

other accepted tests in monitoring for tumor growth recurrence in a patient who has had a tumor

irradiated or surgically removed. Codes 82105 and 82106 are also reimbursable for alpha-fetoprotein

testing used for prenatal (nondiagnostic) gestational age dependent screening for neural tube

defects. Code 86316 for immunoassay for a tumor antigen not elsewhere specified, e.g., CA 50, is

billable "By Report". When a procedure for (CEA) carcinoembryonic antigen (82378) is performed in

combination with Comprehensive Metabolic Panel (code 80053) the maximum

reimbursable fee for code 82378 is $8.00. A test for an oncofetal antigen (tumor marker) is

reimbursable for diagnostic purposes only when used in accordance with the FDA approval criteria for

its use. When 84153 and 84152 or 84154 are billed in combination, the maximum fee for 84152 or

84154 is $21.35.

16. Claims for reimbursement for procedures generally considered to be follow-up testing must be

supported by reporting a specific (presumptive) diagnosis which considers the results of the initial

test(s) as well as the patient's history, symptoms, etc. The ordering practitioner must supply such

diagnosis, or reason for the patient encounter, to the laboratory. For example:

• Code 82172 is reimbursable when performed for diagnostic purposes for a patient with

documented elevated total cholesterol (>240 mg/dl) and an abnormally low HDL cholesterol

level (< 35 mg/dl) and/or documented family history of coronary artery disease (CAD). A

test for apolipoprotein(s) is not reimbursable when used as a screening procedure for

CAD risk assessment.

• Thyroid function tests other than "screen" tests for clinically suspected thyroid dysfunctions

are reimbursable only when indicated for differential diagnosis, to resolve disagreement

with documented clinical impressions, to resolve equivocal

results or to monitor therapeutic regimens of diagnosed thyroid-dysfunctional patients. For

purposes of this rule, a "screen" test is either total thyroxine (84436) or free thyroxine index

(84436 + 84479) or sensitive-TSH (84443).

• Serologic markers that are clinically indicated for staging, management or prognosis of viral

hepatitis B are reimbursable only when it is determined by initial diagnostic testing that the

patient has type B hepatitis.

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17. The fee for presumptive identification of microbial culture isolates includes reimbursement for all

procedures used to presumptively identify the organism, including stains. When definitive

identification is medically necessary and additional methods are used for definitive identification, (e.g.,

molecular methods) use code 87076 or 87077, as applicable, in addition to the appropriate code for

isolation (87040 - 87075).

18. Lymphocyte evaluation by immunophenotyping is reimbursable for analysis of lymphocyte

subpopulations for monitoring of disease activity and therapeutic response in, for example,

immunodeficiency or autoimmune disease, or cancer. Only those antibodies or "markers" FDA

approved or cleared and/or approved by the Department are reimbursable as follows:

• Bill 1 unit of code 86360 when the lab performs an "abbreviated lymphocyte" analysis

panel* by 2 color flow cytometric analysis or any acceptable tube combination out of the

possible four analysis tubes by 3 or 4-color flow cytometric analysis, and reports absolute

CD4 counts with CD8 counts;

• Bill 2 units of code 86360 when the lab performs a "full lymphocyte" analysis panel* by 2, 3

or 4 color flow cytometric analysis and reports absolute CD4 counts with CD8 counts.

Codes 86355, 86357, 86359, 88184, 88185 and 88187 through 88189 are not reimbursable

for a ‘full lymphocyte’ analysis panel when only performing absolute CD4 counts with CD8

counts;

• Bill 1 unit of code 86361 when the lab performs lymphocyte subpopulation counts by a

method other than flow cytometry or microscopy, and reports only absolute CD4 counts

with or without CD8 counts;

• Bill 1 unit of one or more of the codes 86355, 86357, 86359, 86367, 88184 and whenever

appropriate, 1 or more units of 88185, when the lab performs flow cytometric testing using

multiple markers (e.g. lymphoma/leukemia testing). When CD4/CD8 analysis is included, 1

unit of 86360 should be billed in addition, and when CD4 analysis is included (without

CD8), bill 1 unit of 86361 in addition. Codes 86360 and 86361 may not be billed for the

same date of service. 88184 and 88185 should be used for unlisted markers, including

markers used to draw gates, set cursors and monitor variability. Bill 1 unit of the

appropriate interpretation code (88187 through 88189) based on the total number of

markers performed;

• Bill code 88346 or 88350 when the lab performs microscopic or other non-flow cytometric

subset analysis using tagged antibody(ies); bill 1 unit of code 88346 or 88350 per marker.

* "Abbreviated lymphocyte” and "full lymphocyte" panels are as defined by the New York State

Cellular Immunology Proficiency Testing Program.

19. Code 86341 Islet cell antibody is reimbursable when used to differentiate type I from type II

diabetes in patients with equivocal clinical presentation. It is not reimbursable when used as a

predicator of disease, e.g., in first-degree relatives of persons with diabetes mellitus.

Laboratory Procedure Codes

20. Code 87536 HIV-1 quantitation is reimbursable when used in patient management to predict

clinical outcomes, to predict risk of disease progression, and/or to provide information for a decision

to initiate antiretroviral drug therapy or to change treatment regimes. This test is allowed as clinically

indicated up to a maximum of six per year.

21. HIV genotypic/phenotypic drug resistance testing and phenotypic prediction using genotypic

comparison to known databases is a covered service when clinically indicated. Medicaid will

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reimburse each test (87900, 87901, 87903, 87904, 87906) up to a maximum of three times in a 365-

day period across all providers. NYS Medicaid will reimburse for any combination of 87901 and

87903 up to a maximum of four times in a 365-day period across all providers.

Code 87903 reimburses $675.29 for resistance determinations of up to 10 antiviral drugs. Code

87904 should be billed in addition to 87903 to claim reimbursement for additional drug resistance

determinations, using one unit for each (1) additional drug.

When codes 87901, 87903 and 87906 are billed in combination with the same date of service, the

maximum reimbursable fee for any combination of 87901, 87903 and 87906 is $100 less than the

additive maximum fees for the codes.

22. For instrumented screening of PAP smears (codes 88174 and 88175), the following definitions

apply:

• For code 88174, “screening by automated system” means primary examination by a slide

profiling system without human review and primary examination by human review of all

fields of vision selected by a locations-guidance system, with or without quality assurance

manual or automated re-screening.

• For code 88175, “screening by automated systems and manual rescreening” means

primary examination by human review of all or some fields of vision selected by a location

guidance system, and, in addition, full slide review (e.g., AutoScan mode engaged), with or

without quality assurance manual or automated rescreening.

23. Effective September 1, 2004, travel expenses associated with in-home phlebotomy services, i.e.,

blood draws, are reimbursable using code P9604. The recipient must be eligible for in-home

phlebotomy as documented by a qualified ordering practitioner and defined below.

A recipient is eligible for in-home phlebotomy if:

• The recipient is homebound, which means he or she has a condition due to illness or injury

that precludes access to routine medical services outside of his/her residence without

special arrangements for transportation, i.e., ambulance, ambulette, and taxi with

assistance in areas where public transportation is unavailable; or has a condition that

makes leaving the residence medically contraindicated; and

• The recipient is participating in a Medicaid-covered home care program or is currently

receiving a Medicaid-covered home care service, i.e., personal care services, certified

home health agency (CHHA) services, consumer-directed personal assistance services, or

the Long-Term Home Health Care Program (LTHHCP).

Travel expenses are NOT a covered service if they are solely to:

• Draw blood from patients in a skilled nursing facility;

• Draw blood from a recipient who receives medical services in his or her residence from a

professional whose scope of practice authorizes the drawing of blood; or,

• Pick-up and transport a specimen collected by a home health care provider or anyone other

than a laboratory representative.

The laboratory is entitled to only one fee for one-way or round-trip travel to a single address,

regardless of the number of specimens collected or the number of recipients drawn at that location.

There is a limit of 12 claims per recipient per year for in-home phlebotomy service; this allows for 12

round-trips or 12 one-way trips, or any combination of no more than 12 round or one-way trips. The

number of specimens collected per trip must be documented.

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To calculate the appropriate reimbursement amount for claiming travel to and from in-home

phlebotomy services, multiply the number of trips or stops (including the return trip to the laboratory)

by the fee and divide this amount by the number of patients seen. The laboratory will pro-rate when

the claim is submitted based on the number of patients seen on that trip. The "same address" is

defined as a building or complex with the same entrance and egress off of a public road, such as an

apartment complex.

Rules for billing, including pro-rating for multiple recipients:

1. One recipient at one site: A laboratory representative travels from the laboratory to the

home of one recipient and returns to the laboratory without making any other stops. The trip

out and back is paid as a round-trip. The laboratory should submit a single line claim for

$18.70 (2 x $9.35 = $18.70).

2. One recipient at each of multiple sites: A laboratory representative travels in a circuit

from the laboratory to the home of each of six recipients and returns to the laboratory. Each

segment is paid as a one-way trip at a flat rate of $9.35. The laboratory is entitled to a total

of $65.45 (7 x $9.35 = $65.45) but, since a separate claim must be submitted for each

recipient, $65.45 must be divided by the number of recipients, which is six. Each of the six

recipient claims would be submitted for $10.91.

3. Multiple recipients at a single address: A laboratory representative travels from the

laboratory to an apartment complex, draws blood from six recipients and returns to the

laboratory. The laboratory is entitled to one round trip fee of $18.70, but, since a separate

claim must be submitted for each recipient, the $18.70 must be divided by the number of

recipients, which is six. Each of the six recipients' claims would be submitted for $3.12.

4. Multiple recipients at one address + one recipient at each of several additional sites:

A laboratory representative travels from the laboratory to an apartment complex and draws

blood from three recipients; he then continues his circuit to three separate residences, and

draws blood from one recipient at each, and returns to the laboratory.

The laboratory should bill as follows:

The laboratory is entitled to $9.35 for the trip segment from the laboratory to the apartment complex;

For each of the three recipients drawn at separate addresses, the laboratory is entitled to $9.35 trip

segment. The laboratory is also entitled to $9.35 for the return to the laboratory. The total would be

four times $9.35, or $37.40.

The total number of stops are 5 (one stop from the laboratory to the apartment complex, stops at

three recipients' homes and the return trip to the laboratory). The laboratory is entitled to a total of

$46.75 (5 x $9.35 = $46.75), but since a separate claim must be submitted for each recipient, $46.75

must be divided by the number of recipients which is six. Each of the six recipient's claims would be

submitted for $7.79.

24. The Medicaid definition for "date of service" for laboratory providers is the date of specimen

collection. For laboratory tests that use a specimen taken from storage, the date of service is the date

the specimen was removed from storage.

25. NCCI Modifiers:

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Note- NCCI associated modifiers are recognized for NCCI code pairs/related edits. For additional

information please refer to the CMS website: http://www.cms.hhs.gov/NationalCorrectCodInitEd/

-59 Distinct procedural service

-91 Repeat clinical diagnostic laboratory test

26. Organic Acid Codes 83918, 83919, and 83921 will be reimbursable by NYS Medicaid for

members aged 20 years and older with limited diagnoses that relate to acute porphyria, epilepsy,

inborn errors of metabolism, mitochondrial myopathies, dementia, transcobalamin II deficiency, and

biotin dependent carboxylase deficiency.