77078
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.24
Facility
$2.74
Non-Facility
$2.74
Documentation Required
- All services ordered or rendered to Medicare beneficiaries must be signed; providers/suppliers must notify beneficiaries in writing prior to rendering the service if aware the test/item/procedure may not be covered.
- A valid ICD-10-CM diagnosis code that best describes the patient's condition must be reported on the claim; claims without a valid ICD-10-CM code will be returned as incomplete under Section 1833(e).
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- The patient's medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
Key Coverage Criteria
- Bone mass measurement tests are covered when ordered by the treating physician or a qualified non-physician practitioner authorized by state law.
- An initial bone mass measurement is covered (Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless of sites studied).
- A DXA confirmatory test may be performed and covered as a baseline for future monitoring (exception to the 'one type only' rule).
- CPT code 77082 (vertebral fracture assessment) is covered when medically necessary, with symptoms documented and when results are anticipated to be used in patient management.
- 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.
20 Active Policies
L33693 — Peripheral Venous Ultrasound
J09
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
J12
L35007 — Vestibular and Audiologic Function Studies
J12
L35434 — Oximetry Services
J12
L35451 — Peripheral Venous Ultrasound
Related Codes
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