Does 81226 require prior authorization?

No, 81226 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 81226?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

The article does not specify documentation requirements; follow the documentation, medical record, and prior authorization requirements described in LCD MolDX: Repeat Germline Testing L38429 and MolDX program guidance.
For Part A UB04 paper claim forms, enter the DEX Z-Code adjacent to the CPT code in Block 80.
For Part B electronic 5010A1 837P claims, enter the DEX Z-Code adjacent to the CPT code in Loop 2400 or SV101-7.
For Part B paper claims, enter the DEX Z-Code adjacent to the CPT code in Box 19 of the paper claim form.

Coverage for repeat germline testing is determined by the referenced Local Coverage Determination MolDX: Repeat Germline Testing L38429; consult that LCD for specific clinical indications that constitute covered testing.
To report a Molecular Diagnostic Test (MDT) service, submit the appropriate CPT code, include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field, and enter 1 unit of service (UOS).
Pharmacogenomics (PGx) testing is covered when ordered to guide drug selection or dosing for specific drug(s) that are under consideration or in use by the ordering physician and when results will inform clinical management.
CYP2C9 and VKORC1 testing for warfarin dosing is covered only in accordance with the requirements of NCD 90.1.
When MolDX Technical Assessment (TA) forms relevant to the test type are available, completion and submission of those forms are required for successful coverage determinations.
Pharmacogenomics (PGx) testing is covered when ordered to guide selection or dosing of specific drug(s) that the ordering physician is considering for the beneficiary and when the test is likely to identify the necessary alleles/variants to inform therapy.

A58395 — Billing and Coding: MolDX: Pharmacogenomics Testing

J05

L38429 — MolDX: Repeat Germline Testing

J05

A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)

J05

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

J05

L38435

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