Does 81251 require prior authorization?

No, 81251 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 81251?

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

All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Every page of the medical record must be legible and include appropriate patient identification information such as complete name and dates of service.
The record must include the legible signature of the physician or non-physician practitioner responsible for and providing the patient's care.
The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.

Coverage determinations for biomarker testing follow Local Coverage Determination L35062 and services are covered when reasonable and necessary per that LCD.
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.
Report molecular pathology CPT codes for nucleic acid analyses to detect germline or somatic gene variants or to test for histocompatibility antigens (e.g., HLA).
Use HCPCS G0452 with modifier 26 when a pathologist performs the interpretation of a molecular pathology test.
Assign an unlisted molecular pathology CPT code 81479 if the analyte tested is not listed under Tier 2 codes and is not represented by a Tier 1 CPT code.
Report a CPT code described as “full gene sequence” only when the performed assay is a full gene sequence.

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

J05

L36807 — MolDX: Molecular Diagnostic Tests (MDT)

J05

A57100 — Billing and Coding: MolDX: Repeat Germline Testing

J05

L38429 — MolDX: Repeat Germline Testing

J05

A59926

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