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TRICARE Policy Manual 6010.63-M, April 2021
Pathology And Laboratory
Chapter 6
Section 1.1
General
Issue Date:  
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT CODES
80048 - 87622, 87640, 87641, 87650 - 87999, 88104 - 89264, 89330 - 89399
2.0  DESCRIPTION
2.1  Pathology is the medical science and specialty practice that deals with all aspects of disease, but with special reference to the essential nature, the causes, and development of abnormal conditions, as well as the structural and functional changes that result from disease processes.
2.2  The surgical pathology services include accession, examination, and reporting for a specimen which is defined as tissue that is submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. These codes require gross and microscopic examination.
3.0  POLICY
3.1  Pathology and laboratory services are covered except as indicated.
3.2  Surgical pathology procedures, billed by a pathologist, are covered services.
3.3  If the operating surgeon bills for surgical pathology procedures, they will be denied as incidental, since the definitive (microscopic) examination will be performed later, after fixation of the specimen, by the pathologist who will bill separately.
3.4  Dermatologists are qualified to perform surgical pathology services. Therefore, if a dermatologist bills for both the surgical procedure (e.g., Current Procedural Terminology (CPT) code 11100, skin biopsy) as well as the surgical pathology, both procedures are covered in full.
3.5  Human papillomavirus testing (CPT codes 87620 - 87622) is covered as a diagnostic test for the assessment of women with Atypical Squamous Cells of Undetermined Significance (ASCUS) detected during a Pap smear.
3.6  The Nuclear magnetic Resonance (NMR) LipoProfile-2 test, used with the NMR Profiler (CPT codes 83701 and 83704) is proven and covered for the management of lipoprotein disorders associated with cardiovascular disease.
3.7  For transfusion services, refer to Section 2.1.
3.8  AlloMap® for molecular testing is proven for use in cardiac transplant rejection surveillance.
3.9  TRICARE authorized laboratories must maintain accreditation from a Centers for Medicare and Medicaid Services (CMS) “Deemed Status” organization, for example the College of American Pathologists. Does not apply to TRICARE Overseas Program (TOP).
3.10   TRICARE authorized laboratories must meet Clinical Laboratory Improvement Act of 1988 (CLIA ‘88) standards described in 42 CFR Part 493 - Laboratory Requirements. Does not apply to TOP.
4.0  EXCLUSIONS
4.1  Autopsy and postmortem (CPT codes 88000 - 88099).
4.2  Sperm penetration assay (hamster oocyte penetration test or the zona-free hamster egg test) is excluded for Invitro Fertilization (IVF) (CPT code 89329).
4.3  In-vitro chemoresistance and chemosensitivity assays (stem cell assay, differential staining cytoxicity assay and thymidine incorporation assay) are unproven.
4.4  Hair analysis to identify mineral deficiencies from the chemical composition of hair is unproven. Hair analysis testing (CPT code 96902) may be reimbursed when necessary to determine lead poisoning.
4.5  Insemination of oocytes (CPT code 89268).
4.6  Extended culture of oocyte(s) embryo(s) four to seven calendar days (CPT code 89272).
4.7  Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes (CPT code 89280). Assisted oocyte fertilization, microtechnique; greater than 10 oocytes (CPT code 89281).
4.8  Biopsy oocyte polar body or embryo blastomere (CPT code 89290). Biopsy oocyte polar body or embryo blastomere; greater than four embryos (CPT code 89291).
4.9  Cryopreservation reproductive tissue, testicular (CPT code 89335), oocyte(s) (CPT code 89337) and ovarian tissue (CPT code 0058T).
4.10  Storage (per year) embryo(s) (CPT code 89342). Storage (per year) sperm/semen (CPT code 89343). Storage (per year) reproductive tissue, testicular/ovarian (CPT code 89344). Storage (per year) oocyte (CPT code 89346).
4.11  Thawing of cryopreserved, embryo(s) (CPT code 89352). Thawing of cryopreserved, sperm/semen, each aliquot (CPT code 89353). Thawing of cryopreserved, reproductive tissue, testicular/ovarian (CPT code 89354). Thawing of cryopreserved, oocytes, each aliquot (CPT code 89356).
4.12  Oncotype Dx (S3854) is not covered due to the lack of United States (US) Food and Drug Administration (FDA) status.
4.13  OVA1™ test for ovarian cancer.
4.14  The Pathwork® Tissue of Origin Test is unproven to assist in identifying the origin of poorly differentiated, undifferentiated, or metastatic tumors.
4.15  Vitamin D screening in asymptomatic individuals, in the general population, as a preventive measure, and/or during examinations without abnormal findings.
5.0  Effective Dates
5.1  July 23, 2008, for NMR LipoProfile-2 test, used with the NMR Profiler.
5.2  February 19, 2015, for AlloMap® molecular expression testing for cardiac transplant rejection surveillance.
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