TESTS GRANTED WAIVED STATUS UNDER CLIA CPT CODE(S) …

1 TESTS GRANTED WAIVED STATUS UNDER CLIA. CPT CODE(S) TEST NAME MANUFACTURER USE. 81002 Dipstick or tablet reagent urinalysis Various Screening of urine to monitor/diagnose various diseases/conditions, such as non-automated for bilirubin, glucose, diabetes, the state of the kidney or urinary tract, and urinary tract infections hemoglobin, ketone, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen 81025 Urine pregnancy TESTS by visual color Various Diagnosis of pregnancy comparison 82270 Fecal occult blood Various Detection of blood in feces from whatever cause.

2 Benign or malignant G0107 (Contact your (colorectal cancer screening). Medicare carrier for claims instructions.). 82962 Blood glucose by glucose monitoring Various Monitoring of blood glucose levels devices cleared by the FDA for home use 83026 Hemoglobin by copper sulfate non- Various Monitors hemoglobin level in blood automated 84830 Ovulation TESTS by visual color Various Detection of ovulation (optimal for conception). comparison for human luteinizing hormone 85013 Blood count; spun microhematocrit Various Screen for anemia 85651 Erythrocyte sedimentation rate non- Various Nonspecific screening test for inflammatory activity, increased for majority automated of infections, and most cases of carcinoma and leukemia This list includes updates through 6/1/2003.

3 TESTS GRANTED WAIVED STATUS UNDER CLIA. CPT CODE(S) TEST NAME MANUFACTURER USE. 80101QW (This test 1. Phamatech At Home Drug Test Phamatech Screening test for the presence/detection of amphetamine in urine may not be covered (Model 9063). in all instances. Contact your Medicare carrier for claims instructions.). 2. Phamatech QuickScreen One Step Phamatech Amphetamine Test 80101QW (This test 1. ADC CLIA WAIVED Marijuana Advantage Diagnostics Screening test for the presence/detection of cannabinoids (THC) in urine may not be covered (THC) Test Corporation (ADC).)

4 In all instances. Contact your Medicare carrier for claims instructions.). 2. Phamatech At Home Drug Test Phamatech (Model 9078). 3. Phamatech At Home Drug Test Phamatech (Model 9078T). 4. Worldwide Medical Corporation, Worldwide Medical First Check Home Drug Test (THC) Corporation 80101QW (This test 1. Phamatech At Home Drug Test Phamatech Screening test for the presence/detection of cocaine metabolites in urine may not be covered (Model 9073). in all instances. Contact your Medicare carrier for claims instructions.). 2. Phamatech At Home Drug Test Phamatech (Model 9073T).

5 3. Phamatech QuickScreen One Step Phamatech Cocaine Screening Test This list includes updates through 6/1/2003 2. * Newly added WAIVED test system TESTS GRANTED WAIVED STATUS UNDER CLIA. CPT CODE(S) TEST NAME MANUFACTURER USE. 80101QW (This test 1. Phamatech At Home Drug Test Phamatech Screening test for the presence/detection of methamphetamines in urine may not be covered (Model 9068). in all instances. Contact your Medicare carrier for claims instructions.). 2. Phamatech QuickScreen One Step Phamatech Methamphetamine Test 80101QW (This test DynaGen NicCheck I Test Strips Dynagen, Inc.)

6 Detects nicotine and/or its metabolites in urine, which is used as an aid in may not be covered indicating the smoking STATUS of an individual and as an aid in the in all instances. identification of a smoker as a low or high nicotine consumer Contact your Medicare carrier for claims instructions.). 80101QW (This test 1. Phamatech At Home Drug Test Phamatech Screening test for the presence/detection of opiates in urine may not be covered (Model 9083). in all instances. Contact your Medicare carrier for claims instructions.). 2. Phamatech QuickScreen One Step Phamatech Opiate Screening Test 80101QW (This test 1.

7 Phamatech At Home Drug Test Phamatech Screening test for the presence/detection of phencyclidine in urine may not be covered (Model 9133). in all instances. Contact your Medicare carrier for claims instructions.). 2. Phamatech QuickScreen One Step Phamatech PCP Screening Test This list includes updates through 6/1/2003 3. * Newly added WAIVED test system TESTS GRANTED WAIVED STATUS UNDER CLIA. CPT CODE(S) TEST NAME MANUFACTURER USE. 80101QW (This test 1. Advantage Diagnostics Advantage ADC Screening test for the presence/detection of cannabinoids (THC) and cocaine may not be covered Marijuana (THC) and Cocaine Home metabolites in urine in all instances.

8 Drug Test Contact your Medicare carrier for claims instructions.). 2. ADC CLIA WAIVED Marijuana ADC. (THC) and Cocaine Test 3. Forefront Diagnostics Forefront Diagnostics, Drugfree@Home THC/COC Test Kit Inc. 4. Worldwide Medical Corporation, Worldwide Medical First Check Home Drug Test (THC- Corporation COC). 80101QW (This test ADC CLIA WAIVED Multiple Drug ADC Screening test for the presence/detection of cannabinoids (THC), cocaine may not be covered Test Card metabolites, methamphetamines, opiates, and phencyclidine (PCP) in urine in all instances. Contact your Medicare carrier for claims instructions.

9 Alatex Scientific Peace of Mind Advantage Diagnostics Multiple Drugs of Abuse Test Corporation, Ltd. 80101QW (This test Phamatech At Home Drug Test (Model Phamatech Screening test for the presence/detection of amphetamines, cannabinoids may not be covered 9150T) (THC), cocaine metabolites, methamphetamines, and opiates in urine in all instances. Contact your Medicare carrier for claims instructions.). 80101QW (This test Worldwide Medical Corporation, First Worldwide Medical Screening test for the presence/detection of cannabinoids (THC), cocaine may not be covered Check Home Drug Test Panel 4 Corporation metabolites, opiates and methamphetamines in urine in all instances.)

10 (THC-COC-OPI-MET). Contact your Medicare carrier for claims instructions.). This list includes updates through 6/1/2003 4. * Newly added WAIVED test system TESTS GRANTED WAIVED STATUS UNDER CLIA. CPT CODE(S) TEST NAME MANUFACTURER USE. 81002, 1. Bayer Multistick Pro 7G Reagent Bayer Diagnostics Screening of urine to monitor/diagnose various diseases/conditions, such as 82570QW Strips diabetes, the state of the kidney or urinary tract, and urinary tract infections and semi-quantitative measurement of creatinine in urine for the detection of patients at risk for developing kidney damage 2.