Appendix E: Authorization Guidelines for Laboratory, Ob/Gyn, and Radiology Services (Auto Pay List)

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KAISER PERMANENTE OF OHIO APPENDIX E: AUTHORIZATION GUIDELINES FOR LABORATORY, OB/GYN, AND RADIOLOGY SERVICES (AUTO PAY LIST) Kaiser Permanente Provider Manual APPENDIX E Revised September 2012 1 KAISER PERMANENTE OF OHIO Appendix E: Authorization Guidelines for Laboratory, Ob/Gyn, and Radiology Services (Auto Pay List) The Laboratory, Ob/Gyn, and Radiology Services listed below may be performed without a Referral if ordered by a Kaiser Permanente Plan Physician and when performed at a Kaiser Permanente Plan Facility. However, the tests or procedures must be medically appropriate for the Member’s diagnosis and the Member must be eligible for coverage on the date of Service. Reimbursement for these Services will be made in accordance with the terms of the Agreement between Kaiser Permanente and the Plan Provider. Kaiser Permanente Provider Manual APPENDIX E Revised September 2012 2 KAISER PERMANENTE OF OHIO KAISER PERMANENTE AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 00104 ANESTHESIA FOR ELECTROCONVULSIVE THERAPY 1/1/2007 SUBCUTANEOUS HORMONE PELLET IMPLANTATION (IMPLANTATION OF ESTRADIOL AND/OR TESTOSTERONE PELLETS BENEATH THE 11980 SKIN) 1/1/2005 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING 12001 HANDS AND FEE 1/1/2005 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR 12031 EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS 1/1/2005 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 12051 AND/OR MUCOUS MEMBRANES; 2.

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JWBK208-IND-II August 12, 2008 16:22 Char Count= 0 Index of General Terms 395 Index of General Terms 3D clusters (in cytology) polymorphous low grade 131 adiposis dolorosa 281 mesothelial 360 prostatic 220, 222, 224 adnexal tumours 292–4 urine 365 adenoid adrenal medullary chromaffin adenocarcinoma 361 basal carcinoma 234 paraganglioma 276 ␣1-antitrypsin 157 basal epithelioma 234 adrenal pathology 53–4, 275–7, 383 acantholytic squamous cell carcinoma cystic carcinoma 131, 369 adrenocortical adenoma 275–6 285 pharyngeal tonsil 38 adrenocortical carcinoma (ACC) acanthoma 282, 283, 292 adenoma 130–1, 200 275–6 accessory auricles 199 adrenocortical 275–6 adrenocorticotrophic hormone acetic acid artefact 357 basal cell 130–1, 223 (ACTH) 275, 278 achalasia of the cardia 135 bile duct 172 adult achondroplasia 330 bronchioalveolar 91 granulosa cell tumour 249 acinar cell carcinoma/dysplasia 177 Brunner’s gland 142 large bile duct obstruction 164 acinar zones (of liver) 156 canalicular 131 renal tumours 49 acinic cell carcinoma 132, 369 duct 264 respiratory distress syndrome 383 acquired immunodeficiency dysplasia 149–50 T-cell leukaemia 115–16 syndrome (AIDS, see also HIV) flat 149–50 advanced practitioners 359 165, 306–7, 346–7, 364 follicular 268–9 adventitious bursa 342 acral naevus 288 gastric 138 AFP 19 acrodermatitis enteropathica 304 hepatocellular 169–70 age-related changes 68, 75, 196–7, ACTH 275, 278 hyalinising trabecular 271 201 actinic malignum 235 age-related macular degeneration keratosis 283 metanephric 216 (AMD) 196–7 lentigo 288–9
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