76873
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
1.51
Facility
$3.89
Non-Facility
$3.89
Documentation Required
- The patient's medical record must fully support the medical necessity for TRUS and include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For diagnostic tests, report the test result if known; if the result is not available, report the symptoms that prompted performance of the test.
- Documentation supporting the service must be available to Medicare upon request.
- When a referring/ordering physician is required, the claim must report the referring/ordering physician's name and NPI.
Key Coverage Criteria
- Transrectal ultrasound (TRUS) is covered when it is medically necessary and consistent with the related Local Coverage Determination (LCD) with supporting documentation in the medical record.
- An IDTF must be credentialed and approved by Palmetto GBA provider enrollment to bill Medicare for a specific diagnostic procedure or material.
- Additional services and supplies (e.g., radiopharmaceuticals, special contrast agents, medications) are payable to an IDTF when the diagnostic test itself is payable and the supplies are commonly separately reimbursed to a physician in an office setting.
- A supervising physician for an IDTF must be licensed in the state(s) where tests are performed, enrolled in Medicare, not excluded, meet proficiency standards for tests supervised, and provide general supervision for no more than three IDTF sites.
- An interpreting physician must be licensed in the state(s) where tests are performed, enrolled in Medicare, not excluded, and qualified to interpret the types of tests (codes) listed on the IDTF enrollment application.
- An IDTF technician must meet applicable state licensure and/or certification standards at the time of enrollment and/or at the time tests are performed and be qualified to perform the types of tests (codes) listed in the enrollment application.
13 Active Policies
L33578 — Transrectal Ultrasound
J06
A57427 — Billing and Coding: Transrectal Ultrasound
J06
L33693 — Peripheral Venous Ultrasound
J09
L35007 — Vestibular and Audiologic Function Studies
J12
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
Related Codes
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