Does 0528U require prior authorization?

No, 0528U does not require prior authorization (high confidence). Code is covered without prior authorization.

`0528U`

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Report the appropriate CPT code for the Molecular Diagnostic Test service on the claim.
Enter 1 unit of service (UOS) for the Molecular Diagnostic Test service on the claim.
For Part B claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field: Loop 2400 or SV101-7 for 837P electronic claims and Item 19 for paper claims.
For Part A claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field: Line SV202-7 for 837I electronic claims and Block 80 for the UB04 claim form.

To report a Molecular Diagnostic Test (MDT) service, submit the appropriate CPT code, include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field, and enter 1 unit of service (UOS).
Molecular syndromic infectious disease panels are covered when billed with the appropriate proprietary CPT®/PLA code (or CPT® 87999 if no specific code exists) and accompanied by ICD-10-CM diagnosis codes that support medical necessity documented in the patient record.
FDA-approved or cleared molecular infectious disease tests performed consistent with their intended use labeling are covered without a DEX Z-Code and Technical Assessment when billed with appropriate ICD-10-CM diagnosis codes and supporting documentation.
Expanded (>5 pathogens) respiratory (RP/PNP) and gastrointestinal (GI) panels are covered if billed from place of service (POS) 19, 21, 22, or 23, or if ordered by an appropriate specialist depending on beneficiary immune status and the specialist is diagnosing/treating the beneficiary.
For immune-compromised beneficiaries, expanded panels (RP/PNP/GI/other panels) are covered when ordered by a specialist in Infectious Diseases, Oncology, Transplant, Pulmonology (for RP/PNP), or Gastroenterology (for GI) who is diagnosing and treating the beneficiary.
Pre-transplant evaluation testing for an immune-compromised beneficiary is covered regardless of symptoms when clear documentation of the pre-transplant evaluation accompanies the claim.

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

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A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)

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A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J05

L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J05

Ask Verity about documentation requirements, denial risks, or coverage in your state.