Download The following list of procedure codes requires a

Procedures Requiring a Valid Diagnosis – HK/HFP
The following list of procedure codes requires a valid diagnosis code which is related to the
service rendered for the Healthy Kids and Healthy Family lines of business. Unrelated or
invalid diagnosis codes are subject to denial.
Procedure
Code
59025
68761
76856
76857
Procedure Description
Fetal Non-Stress Test
Closure Of The Lacrimal Punctum; By Plug, Each
Ultrasound, Pelvic (Nonobstetric), B-Scan And/Or Real Time With Image Documentation; Complete
Ultrasound, Pelvic (Nonobstetric), B-Scan And/Or Real Time W/Image Documentation; Limited/Follow-Up
80048
80050
80053
80061
80069
80170
Basic Metabolic Panel
General Health Screen Panel
Comprehensive Metabolic Panel
Lipid Panel
Renal Function Panel
Gentamicin
80299
81001
81002
81243
82043
82247
Quantitation Of Therapeutic Drug, Not Elsewhere Specified
Urinalysis; Automated, With Microscopy
Urinalysis,By Dipstick/Tablet Reagent;Non-Automated,W/0 Micr
Fmr1 (Fragile X Mental Retardation) Gene Analysis; Evaluation To Detect Abnormal (Eg Expanded) Alleles
Albumin; Urine, Microalbumin, Quantitative
Bilirubin; Total
82248
82306
82570
82607
82746
82962
Bilirubin; Direct
Calcifediol (25-Oh Vitamin D-3)
Creatinine; Other Source
Cyanocobalamin (Vitamin B-12)
Folic Acid; Serum
Glucose, Blood By Glucose Monitoring Device(S) Cleared By The Fda Specifically For Home Use
82977
83013
83014
83036
83540
83615
Glutamyltransferase, Gamma (Ggt)
Helicobacter Pylori; Breath Test Analysis For Urease Activity, Non-Radioactive Isotope (E.G C-13)
Helicobacter Pylori, Breath Test Analysis; Drug Administration
Hemoglobin, Glycosylated (A1c)
Iron
Lactate Dehydrogenase (Ld), (Ldh)
83735
84100
84132
84153
84295
Magnesium
Phosphorus Inorganic (Phosphate)
Potassium; Serum
Prostate Specific Antigen (Psa); Total
Sodium; Serum
CenCal HEALTH Improving the health and well-being of people on the Central Coast
4050 Calle Real, Santa Barbara CA 93110 | 1288 Morro St, Suite 101, San Luis Obispo, CA 93401 | (800) 421-2560 | www.cencalhealth.org
Page 1 of 3
Procedure
Code
Procedure Description
84439
84443
84478
84550
84702
84703
Thyroxine; Free
Thyroid Stimulating Hormone (Tsh)
Triglycerides
Uric Acid; Blood
Gonadotropin, Chorionic (Hcg); Quantitative
Gonadotropin, Chorionic (Hcg); Qualitative
85007
85025
85027
85045
85652
86038
Blood Count; Blood Smear Microscopic Examination With Manual Differential Wbc Count
Blood Count; Complete (Cbc), Automated And Automated Differential Wbc Count
Blood Count; Complete (Cbc), Automated (Hgb, Hct, Rbc, Wbc And Platelet Count)
Blood Count; Reticulocyte, Automated
Sedimentation Rate, Erythrocyte; Automated
Antinuclear Antibodies, (Ana)
86140
86200
86431
86592
86704
86706
C-Reactive Protein
Cyclic Citrullinated Peptide (Ccp), Antibody
Rheumatoid Factor; Quantitative
Syphilis Test; Qualitative (Eg, Vdrl, Rpr, Art)
Hepatitis B Core Antibody (Hbcab), Total
Hepatitis B Surface Antibody (Hbsab)
86708
86880
86900
86901
87040
87045
Hepatitis A Antibody (Haab), Total
Antihuman Globulin Test (Coombs Test); Direct, Each Antiserum
Blood Typing; Serologic; Abo
Blood Typing; Serologic; Rh (D)
Culture, Bacterial; Blood, With Isolation And Presumptive Identification Of Isolates
Culture, Bacterial; Feces, With Isolation And Preliminary Examination, Salmonella And Shignella Spec
87088
87177
87186
87209
87340
87338
87427
87491
Culture, Bacterial; With Isolation And Presumptive Identification Of Isolates, Urine
Ova And Parasites, Direct Smears, Concentration And Identification
Susceptibility Studies, Antimicrobial Agent; Microdilution Or Agar Dilution, Each Multi-Antimicrobia
Smear, Primary Source W/ Interpretation; Complex Special Stain For Ova And Parasites
Infectious Agent Antigen Detection; Hepatitis B Surface Antigen (Hbsag)
Infectious Agent Antigen Detection By Immunoassay Technique (Eg, Enzyme Immunoassay (EIA), Enzymelinked Immunosorbent Assay (ELISA), Immunochemiluminometric Assay (IMCA), Qualitative or
Semi=Quantitative, Multiple-Step Method; Helicobacter Pylori, Stool
Infectious Agent Antigen Detection By Enzyme Immunoassay Technique, ...; Shiga-Like Toxin
Infectious Agent Detection By Nucleic Acid; Chlamydia Trachomatis, Amplified Probe Technique
87522
87591
87621
Infectious Agent Detection By Nucleic Acid (Dna Or Rna); Hepatitis C, Quantification, Includes Reverse
Transcription When Performed
Infectious Agent Detection By Nucleic Acid; Neisseria Gonorrhoeae, Amplified Probe Technique
Infectious Agent Detection By Nucleic Acid (Dna Or Rna); Papillomavirus, Human, Amplif Probe Techni
87902
Infectious Agent Genotype Analysis By Nucleic Acid (Dna Or Rna); Hepatitis C Virus
CenCal HEALTH Improving the health and well-being of people on the Central Coast
4050 Calle Real, Santa Barbara CA 93110 | 1288 Morro St, Suite 101, San Luis Obispo, CA 93401 | (800) 421-2560 | www.cencalhealth.org
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Procedure
Code
Procedure Description
88141
Cytopathology, Cervical Or Vaginal; Requiring Interpretation By Physician
88175
92060
Cytopathology, Cervical Or Vaginal (Any Reporting System), Collected In Preservative Fluid, Automated Thin
Layer Preparation; With Screening By Automated System And Manual Rescreening Or Review, Under
Physician Supervision
Sensorimotor Examination With Multiple Measurements Of Ocular Deviation W/Interpretation And Report
92134
92225
92235
Scanning Computerized Opthalmic Diagnostic Imaging, Posterior Segment, W/Interpretation And Report,
Uni- Or Bilateral; Retina
Ophthalmoscopy, Extended, With Retinal Drawing, With Interpretation And Report; Initial
Fluorescein Angiography With Interpretation And Report
93880
99173
J0295
J0697
J2001
J2180
Duplex Scan Of Extracranial Arteries; Complete Bilateral Study
Screening Test Of Visual Acuity, Quantitative, Bilateral (See Remarks)
Injection, Ampicillin Sodium/Sulbactam Sodium, Per 1.5 Gm
Injection, Sterile Cefuroxime Sodium, Per 750 Mg
Injection, Lidocaine, Hcl For Intravenous Infusion, 10 Mg
Injection, Meperidine And Prometha
J2370
J2710
J3360
J8501
Injection, Phenylephrine Hcl, Up T
Injection, Neostigmine Methylsulfa, Up To 0.5 Mg
Injection, Diazepam, Up To 5 Mg
Aprepitant, Oral, 150mg (Crossover Claims Only)
CenCal HEALTH Improving the health and well-being of people on the Central Coast
4050 Calle Real, Santa Barbara CA 93110 | 1288 Morro St, Suite 101, San Luis Obispo, CA 93401 | (800) 421-2560 | www.cencalhealth.org
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