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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