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.