Does 81261 require prior authorization?

No, 81261 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 81261?

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

When required, enter the test identifier or short narrative (e.g., 'Initial Work-Up …', 'ThyraMIR', 'Oncomine DX', 'ColonSeq', 'LungSeq', 'MyPRS') in the claim comment/narrative field (Part B: Loop 2400 NTE02 or SV101-7 for 5010A1 837P; Part A: Loop SV202-7 for 837I or Block 80 for UB04; paper: Box 19 or attachment).
For Rosetta Cancer Origin and VeriStrat claims submit a brief 'Initial Work-Up …' comment (under 80 characters) indicating preliminary pathology/imaging or predictive-testing evaluation has been performed.
For OVA1 claims enter 'The patient meets all 3 FDA OVA1 criteria' in the claim narrative (Loop 2400 NTE02, SV101-7, Loop SV202-7, Block 80, or Box 19 as applicable).
Claims using CPT 81479 for specific biomarkers must include a description of the testing performed in the claim narrative/remarks.

Oncomine DX Test (CPT 0022U) is covered when billed with CPT 0022U and the claim narrative contains the identifier 'Oncomine DX'.
Rosetta Cancer Origin Test (CPT 81479) is covered when conventional surgical pathology and/or imaging work-up is unable to identify a primary neoplastic site and an 'Initial Work-Up …' comment is submitted on the claim.
VeriStrat assay (CPT 81538) is covered when a preliminary predictive testing evaluation has been performed prior to ordering and an 'Initial Work-Up …' comment is submitted on the claim.
OVA1 proteomic assay (CPT 81503) is covered for women >18 years old who have an ovarian mass and have surgery planned; the claim must include the narrative 'The patient meets all 3 FDA OVA1 criteria'.
PROGENSA PCA3 (CPT 81313) is covered for appropriate prostate indications when the claim contains 'PCA3' and one of the ICD-10-CM codes listed in ICD-10-CM Codes that Support Medical Necessity Group 9.
MyPRS genetic expression profile testing (CPT 81479) is covered when 'MyPRS' is entered in box 19 (or electronic equivalent) and the claim includes one of the ICD-10-CM codes listed in ICD-10-CM Codes that Support Medical Necessity Group 24.

L38835 — MolDX: Minimal Residual Disease Testing for Cancer

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L36807 — MolDX: Molecular Diagnostic Tests (MDT)

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

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A59004 — Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers

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