Does 81459 require prior authorization?

No, 81459 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 81459?

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 medical record must document that the testing is expected to influence treatment and include the ordering physician/NPP history and physical, exam findings, problems/diagnoses, and relevant data (e.g., lab tests, imaging).
The laboratory or billing provider must retain the physician requisition that sets forth the diagnosis/ICD-10-CM code that warrants the test(s).
Performing laboratory documentation (when requested) must include lab accreditation, test requisition, test records/procedures, preliminary and final reports, and quality control records.
For laboratory-developed tests (LDTs)/protocols (when requested) documentation must include assay description, lab/manufacturer, comparable assays/services (if relevant), and evidence of analytical validity, clinical validity, and clinical utility.

Coverage is allowed for targeted genomic sequence analysis panels for treatment of solid organ neoplasms when the panel is a DNA analysis panel containing at least 5 gene tests for molecular biomarkers that meet Medicare coverage criteria.
Coverage is allowed when the genomic testing is expected to influence the treatment of the condition (i.e., documentation supports that test results will affect clinical management of the solid organ neoplasm).
Genomic testing of acquired conditions such as malignancies, including separate malignancies developing at different times, is permitted when medically reasonable and necessary to assess response or other clinically relevant criteria.
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).
A molecular or genomic test may be covered when it provides new clinical diagnostic information that cannot be obtained from any other test or combination of tests and is reasonable and necessary for management of the Medicare beneficiary.
A molecular panel is coverable when the medical record documents that the entire panel is reasonable and necessary for the beneficiary’s specific medical problem and will be used in patient management.

A57858 — Billing and Coding: MolDX: Next-Generation Sequencing for Solid Tumors

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

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L38158 — MolDX: Next-Generation Sequencing for Solid Tumors

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L36807 — MolDX: Molecular Diagnostic Tests (MDT)

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