80061
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- The medical record must document and satisfy the criteria required for any NCCI-associated modifier that is reported.
- Claims must follow NCCI coding guidelines and applicable code-combination rules prior to billing Medicare.
- Documentation supporting that tests meet 'reasonable and necessary' criteria and applicable frequency limits must be maintained per Novitas LCD L35099.
- Medical record must contain the physician's order and documentation that the physician reviewed and used the laboratory result to manage the beneficiary's specific medical problem.
Key Coverage Criteria
- Laboratory tests are covered when they meet the reasonable and necessary clinical criteria and frequency limitations specified in Novitas LCD L35099.
- Procedure codes are covered for the ICD-10-CM diagnoses listed as covered in the Medicare NCDs referenced at the CMS NCD ICD-10 laboratory list.
- A laboratory service is reasonable and necessary only when ordered by a physician who uses the test result in the management of the beneficiary's specific medical problem.
- A laboratory result must be reported promptly to the ordering physician and the physician must use that result prior to ordering a similar subsequent laboratory test to qualify for separate payment.
- Glucose monitoring laboratory services are covered only when they meet laboratory service coverage criteria, including an order and clear physician use of the laboratory result prior to any similar subsequent laboratory order.
- Medicare Part B may pay for a glucose monitoring device and related disposable supplies under the DME benefit when the equipment is used in the beneficiary's home (or an institution used as a home).
10 Active Policies
L35099 — Frequency of Laboratory Tests
J12
A56420 — Billing and Coding: Frequency of Laboratory Tests
J12
NOVITAS-L35099 — Frequency of Laboratory Tests
JL MAC Part B
AMBETTER-CP.BH.124 — Attention Deficit Hyperactivity Disorder Assessment and Treatment
BCBSNM-MED201.030
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.