78195
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
1.17
Facility
$16.87
Non-Facility
$16.87
Documentation Required
- 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.
Key Coverage Criteria
- 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).
- An IDTF must be credentialed and approved by Palmetto GBA provider enrollment to bill Medicare for a specific diagnostic procedure or material.
15 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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