Does 78351 require prior authorization?

No, 78351 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 78351?

Medicare facility rate: $12.36. Non-facility rate: $12.36. Work RVU: 0.29.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.29

Facility

$12.36

Non-Facility

$12.36

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.

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.
Bone mass measurement services are covered when they meet the clinical indications and medical necessity criteria specified in the related Local Coverage Determination L39268.
Bone mass measurement is covered when performed with a covered testing modality (dual-energy x-ray absorptiometry (DXA), radiographic absorptiometry (RA), bone sonometry (ultrasound), single energy x-ray absorptiometry (SEXA), or quantitative computed tomography (QCT)).

CGS-L36460 — Bone Mass Measurement

J18 MAC Part B

PALMETTO-L39268 — Bone Mass Measurement

JJ Part B

L39268 — Bone Mass Measurement

A57132 — Billing and Coding: Bone Mass Measurement

AETNA-CPB-0134 — Bone Mass Measurements

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