81490
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- 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.
Key Coverage Criteria
- Coverage determinations for biomarker testing follow Local Coverage Determination L35062 and services are covered when reasonable and necessary per that LCD.
- 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.
- Individual gene tests billed separately are coverable when the medical record documents that each individual gene test is reasonable and necessary for the beneficiary’s management.
- When using next generation sequencing (NGS), genes assayed in parallel for the same indication on the same date of service are considered a single panel and may be billed as such when reasonable and necessary.
- Advanced diagnostic laboratory tests (ADLTs) are allowable only when they provide new clinical diagnostic information that cannot be obtained from any other test or combination of tests (per 42 CFR 414.502).
20 Active Policies
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
A59649 — Billing and Coding: MolDX: Proteomics Testing
J05
A58918 — Billing and Coding: Molecular Pathology and Genetic Testing
J09
L39367 — Genetic Testing in Oncology: Specific Tests
J09
L34519
Related Codes
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