Does 38542 require prior authorization?

No, 38542 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 38542?

Medicare facility rate: $469.62. Non-facility rate: $469.62. Work RVU: 7.75.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

7.75

Facility

$469.62

Non-Facility

$469.62

For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
When an ABN is used, Form CMS-R-131 must be signed by the beneficiary; for Part A MAC claims include occurrence code 32 and the ABN date on the claim.
Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed.
Hospital inpatient claims must report the principal diagnosis in UB-04 FL67 and the admitting diagnosis in FL69, with up to eight additional ICD-10-CM codes in FLs 67A-67Q as applicable.

Sentinel lymph node biopsy is covered for identification, removal, and pathologic evaluation of sentinel lymph nodes to stage and assess regional lymph node metastasis for malignant tumors.
Preoperative lymphoscintigraphy to locate sentinel node(s) is covered and should be reported separately when performed prior to the surgical procedure.
Injection of radioactive tracer or vital dye for sentinel node localization is covered when performed without lymphoscintigraphy or when performed by the operating surgeon, reported with the appropriate injection code.
Under Medicare Part B, CPT codes 38500, 38510, 38525 and 38530 are payable in inpatient hospital (21), outpatient hospital (22) and ambulatory surgical center (24) places of service.
CPT codes 38792, 38900 and 78195 are payable in office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgical center (24), and independent clinic (49); CPT 78195 global/TC is payable in office (11) and independent clinic (49).

A52437 — Billing and Coding: Sentinel Lymph Node Biopsy Medical Policy Article

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