Berkshire Health Systems - Pittsfield, Massachusetts (MA ...
BERKSHIRE HEALTH SYSTEM LABORATORIES
Berkshire Medical Center
Fairview Hospital
Advance Beneficiary Notice/Waiver (ABN) for Medicare Patients Only:
A physician office should request the patient sign an ABN only when there is a reason to believe that payment for a laboratory test will be denied:
Some common examples are:
❖ a limited coverage test with no diagnostic information provided.
❖ a limited coverage test (NCD or LMRP) under local medical review
with diagnostic information or diagnosis code provided that is not
listed in the policy as covered.
❖ a test that is not a FDA-approved
National Coverage Decisions are for the following 22 Lab Test Groupings – there are actually 75 individual tests that are under National Coverage Decision. They are listed as follows:
|TEST |TEST NAME |CPT |COST |
|AFP |ALPHA FETOPROTEIN |82105 |$87.02 |
| | | | |
|BLOOD COUNTS | | | |
| |BLOOD COUNT HEMOCRIT |85014 |$13.69 |
| |BLOOD COUNT HEMOGLOBIN |85018 |$13.69 |
| |CBC WITH AUTOMATED WBC DIFF |85025 |$40.31 |
| |CBC WITH MANUAL WBC DIFF |85027 | |
| | | | |
|CA 15-3/27.29 |IMMUNOASSAY TUMOR ANTIGEN |86300 |$72.09 |
| | | | |
|CA 19.9 |IMMUNOASSAY TUMOR ANTIGEN |86301 |$60.51 |
| | | | |
|CA 125 |IMMUNOASSAY TUMOR ANTIGEN |86304 |$64.85 |
| | | | |
|CEA |CARCINOEMBRYONIC ANTIGEN |82378 |$92.97 |
| | | | |
|DIGOXIN |DIGOXIN |80162 |$65.07 |
| | | | |
|GGT |GLUTAMYL TRANSFERASE, GAMMA |82977 |$47.75 |
| | | | |
|GLUCOSE |GLUCOSE, QUANTITATIVE |82947 |$19.22 |
| | | | |
|GLYCO |HEMOGLOBIN; GLYCATED (A1C) |83036 |$48.31 |
| | | | |
|HCG |GONADOTROPIN CHORIONIC QUANT |84702 |$73.76 |
| | | | |
|HELICOBACTER |BREATH |83013 |$188.53 |
| |SERUM ANTIBODY |86677 |$65.27 |
| |STOOL |87338 |$81.84 |
| | | | |
|HEPATITIS |HEPATITIS A ANTIBODY |86709 |$49.75 |
| |HEPATITIS B CORE ANTIBODY |86705 |$59.07 |
| |HEPATITIS B SURFACE ANTIGEN |87340 |$52.43 |
| |HEPATITIS C ANTIBODY |86803 |$72.47 |
| | | | |
|HIV (DIAGNOSTIC) |HIV-1 & HIV-2 SINGLE ASSAY |86703 |$35.00 |
| |HIV WESTERN BLOT |86689 |$124.60 |
| |HIV 1 AMPLIFIED PROBE |87535 |$127.63 |
| | | | |
|HIV (PROGNOSIS) |HIV1 QUANT |87536 |$217.71 |
| | | | |
| | | | |
|IRON STUDIES |FERRITIN |82728 |$66.76 |
| |IRON |83540 |$31.77 |
| |IRON BINDING CAPACITY (TIBC) |83550 |CALCULATION |
| |TRANSFERRIN |84466 |$62.59 |
| | | | |
|LIPIDS |LIPID PANEL |80061 |$66.76 |
| |CHOLESTEROL SERUM, TOTAL |82465 |$21.33 |
| |LIPOPROTEIN, DIRECT (HDL) |83718 |$51.37 |
| |LIPOPROTEIN, DIRECT (LDL) |83721 |$43.78 |
| |TRIGLYCERIDES |84478 |$28.21 |
| | | | |
|PSA |PROSTATIC SPECIFIC ANTIGEN TOTAL |84153 |$90.13 |
| | | | |
| | | | |
|PTT |THROMBOPLASTIN TIME, PARTIAL |85730 |$29.43 |
| | | | |
|PT |PROTHROMBIN TIME |85610 |$19.27 |
| | | | |
|THYROID | | | |
| |THYROXINE - FREE |84439 |$53.33 |
| |THYROID STIMULATING HORMONE |84443 |$82.33 |
| | | | |
| | | | |
|URINE |CULTURE BACTERIAL IDENTIFICATION |87088 |$39.64 |
| |SENSITIVITY STUDIES DISK METHOD |87184 |$33.79 |
| |SENSITIVITY STUDIES MICROTITER |87186 |$37.32 |
| | | | |
Revised C. Jenks 12/29/11
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