Does 81309 require prior authorization?

No, 81309 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 81309?

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

Enter the appropriate CPT code on the claim for the PIK3CA targeted gene sequencing service.
Select and include the appropriate diagnosis for the patient (e.g., HR-positive, HER2-negative advanced/metastatic breast cancer) on the claim.
Labs may submit required supplemental information using SV101-7 or SV202-7 (SV202-7 preferred) or alternatively the NTE field.
For Part B claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field: Loop 2400 or SV101-7 for 5010A1 837P electronic claims and Box 19 for paper claims.

PIK3CA targeted gene sequencing is indicated to detect PIK3CA mutations in patients with hormone receptor (HR)-positive, HER2-negative, advanced or metastatic breast cancer (postmenopausal women and men) who have progressed on or after an endocrine-based regimen when results will inform treatment with alpelisib (Piqray).
PIK3CA targeted gene sequencing is covered to detect PIK3CA mutations in postmenopausal women and men with hormone receptor (HR)-positive, HER2-negative advanced or metastatic breast cancer who have progressed on or after an endocrine-based regimen to determine eligibility for alpelisib (Piqray).
The test must be an FDA-approved PIK3CA diagnostic test when used to identify patients for treatment with FDA-approved alpelisib (Piqray).
When a molecular panel of 5–50 genes is ordered, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) instead of submitting individual single-gene CPT codes.
When 51 or more genes are ordered for molecular biomarkers, bill the appropriate large-panel CPT code (81455 or 81456) rather than individual gene codes.
When a panel contains more than one but fewer than five genes, use the corresponding existing panel CPT code or CPT 81479 (unlisted molecular pathology procedure) if no specific panel CPT exists.

L38429 — MolDX: Repeat Germline Testing

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A55200 — Billing and Coding: MolDX: PIK3CA Gene Tests

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A57100 — Billing and Coding: MolDX: Repeat Germline Testing

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L36807 — MolDX: Molecular Diagnostic Tests (MDT)

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

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