Does 78469 require prior authorization?

Yes, 78469 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 78469?

Medicare facility rate: $16.80. Non-facility rate: $16.80. Work RVU: 0.90.

HCPCS/CPT

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Work RVU

0.90

Facility

$16.80

Non-Facility

$16.80

The patient's medical record must include the ordering provider's assessment related to the patient's complaint for that visit.
The medical record must include relevant medical history and results of pertinent tests and procedures.
Office visit records and operative reports must be signed and dated; all services ordered or rendered to Medicare beneficiaries must be signed.
When using the -GA modifier and ABN, Form CMS-R-131 must be signed by the beneficiary (or properly witnessed if the beneficiary refuses to sign) to indicate acceptance of payment responsibility.

For services that require a referring or ordering physician, the claim must report the referring/ordering physician's name and NPI.
Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed; otherwise the claim will be returned as incomplete under SSA Section 1833(e).
For diagnostic tests, the claim should report the test result if known, otherwise report the symptoms that prompted the test.
If a service is likely to be non-covered, an Advance Beneficiary Notice (ABN) may be used and the appropriate modifier (GA, GX, GY, or GZ) should be appended to the claim as applicable.
Cardiovascular nuclear medicine testing is reimbursable for risk assessment or re-evaluation in asymptomatic patients or patients with stable symptoms who have known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, provided the patient has not undergone a revascularization procedure within the prior 2 years.
Blood pool scan to assess left ventricular ejection fraction prior to implantation of an implantable cardioverter-defibrillator (ICD) or biventricular pacemaker is covered when the medical record documents the intended plan for device insertion and the test result.

L33560 — Cardiovascular Nuclear Medicine

J06

A56743 — Billing and Coding: Cardiovascular Nuclear Medicine

J06

L33693 — Peripheral Venous Ultrasound

J09

L35434 — Oximetry Services

J12

L35451 — Peripheral Venous Ultrasound

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