78261
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.67
Facility
$12.24
Non-Facility
$12.24
Documentation Required
- The IDTF must have Palmetto GBA provider enrollment approval listing the specific CPT/HCPCS codes the facility is authorized to bill for Medicare beneficiaries.
- Claims must be supported by documentation showing the supervising and interpreting physicians are licensed in the state(s) of service, enrolled in Medicare, not excluded, and meet any stated proficiency or specialty requirements.
- The IDTF enrollment application must list the types of tests (codes) the interpreting physicians and technicians are qualified to interpret or perform.
- For services tied to procedure-specific qualifications (e.g., mammography), documentation of facility certifications (e.g., FDA mammography certification) and technician credentials must be maintained and available for claim support.
Key Coverage Criteria
- 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.
- For each CPT/HCPCS code listed in the policy, the supervising physician and technician must meet the specialty and certification qualifications specified in the policy’s code-to-qualification mapping to be reimbursable by Medicare.
10 Active Policies
L33693 — Peripheral Venous Ultrasound
J09
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
J12
L37371 — Electroretinography (ERG)
J12
L35007 — Vestibular and Audiologic Function Studies
J12
L35434 — Oximetry Services
Related Codes
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