Does 78816 require prior authorization?

Yes, 78816 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 78816?

Medicare facility rate: $44.50. Non-facility rate: $44.50. Work RVU: 0.00.

HCPCS/CPT

Prior Auth Required

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

Work RVU

0.00

Facility

$44.50

Non-Facility

$44.50

Claims must meet the reasonable and necessary documentation requirements specified in LCD L35391; refer to that LCD for required medical record elements and prior authorization rules.
Retain and provide copies of hard-copy output with analysis of all data (including bidirectional vascular flow or imaging when provided) in the patient record.
Document clinical findings (e.g., signs/symptoms) and clinical decision rules (Wells score) supporting the medical necessity for the ultrasound.
For outpatient non-active cancer patients with Wells score <2, include the positive D-dimer result in the record prior to performing ultrasound.

Multiple imaging studies in oncology are covered only when reasonable and necessary as defined by Local Coverage Determination L35391.
Perform peripheral venous ultrasound to evaluate clinical signs or symptoms suggestive of acute or new-onset deep vein thrombosis (e.g., extremity swelling, tenderness, erythema).
Perform venous ultrasound to investigate DVT as the source of a confirmed pulmonary embolism.
Repeat or perform venous ultrasound for patients with known venous thrombosis who have a clinical change and where documented change in thrombus burden would alter management or therapy.
Perform venous ultrasound to evaluate postthrombotic (postphlebitic) syndrome in patients with symptoms consistent with PTS (e.g., chronic leg pain, heaviness, swelling, itching, or leg ulcers).
Perform venous ultrasound to evaluate suspected valvular incompetence in patients with symptomatic chronic venous insufficiency or symptomatic varicose veins when the result will confirm diagnosis prior to treatment.

L33693 — Peripheral Venous Ultrasound

J09

A56848 — Billing and Coding: Multiple Imaging in Oncology

J12

L37371 — Electroretinography (ERG)

J12

L35391 — Multiple Imaging in Oncology

J12

A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)

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