Does 72149 require prior authorization?

No, 72149 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 72149?

Medicare facility rate: $11.24. Non-facility rate: $11.24. Work RVU: 1.74.

Verity

`72149`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

1.74

Facility

$11.24

Non-Facility

$11.24

Documentation Required

Claims must meet the reasonable and necessary documentation requirements specified in LCD L35391; refer to that LCD for required medical record elements and prior authorization rules.
Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.
Title XVIII of the Social Security Act, §1842(p)(1) states that each claim submitted by a physician or practitioner shall include the appropriate diagnosis code (or codes)... For services from physicians and (§1842(b)(18)(C)) practitioner submitted with an ICD-10 code that is missing, invalid, or truncated, contractors must return the billed service to the provider as unprocessable in accordance with CR 1910, Transmittal 1728, dated November 1, 2001 (MCM Part 3, Claim Process §3005.4(p)).

Key Coverage Criteria

Multiple imaging studies in oncology are covered only when reasonable and necessary as defined by Local Coverage Determination L35391.
T82.535S | Leakage of umbrella device, sequela
M84.38XP | Stress fracture, other site, subsequent encounter for fracture with malunion
M84.38XS | Stress fracture, other site, sequela
M84.451A | Pathological fracture, right femur, initial encounter for fracture
S32.2XXD | Fracture of coccyx, subsequent encounter for fracture with routine healing

20 Active Policies

L33693 — Peripheral Venous Ultrasound

J09

A56848 — Billing and Coding: Multiple Imaging in Oncology

J12

L35391 — Multiple Imaging in Oncology

J12

A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)

J12

L35007 — Vestibular and Audiologic Function Studies

Have a follow-up question?

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

42 CFR 410.32 and 410.33 indicates that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §§40, 40.1.4 Magnetic Resonance Imaging (MRI) Procedures and Payment Requirements. Effective January 1, 2017 separate payment for the contrast media and the need to use the appropriate HCPCS “Q” code (Q9945 – Q9954; Q9958-Q9964) for the contrast medium utilized in performing the service.

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §100.1 describes how physicians should handle billing when two providers read a diagnostic radiologic procedure.

L35434 — Oximetry Services

J12

L35451 — Peripheral Venous Ultrasound

J12

L37371 — Electroretinography (ERG)

J12

NORIDIAN-L34220 — Lumbar MRI

JF Part B

NOVITAS-L35391 — Multiple Imaging in Oncology

JL MAC Part B

A57807 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)

CARELON-imaging-of-the-spine-2025-11-15 — Imaging of the Spine

CARELON-imaging-of-the-spine-2023-09-10 — Imaging of the Spine

CARELON-imaging-of-the-spine-2024-10-20 — Imaging of the Spine

L37281 — Lumbar MRI

A57207 — Billing and Coding: Lumbar MRI

CARELON-site-of-care-for-advanced-imaging-2024-11-17 — Site of Care for Advanced Imaging

A58559 — Billing and Coding: Independent Diagnostic Testing Facilities (IDTF)

L34220 — Lumbar MRI

UHC-POL-mri-ct-scan-site-of-service — Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan – Site of Service

72149