81539
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
- The submitted medical record must support the use of the selected ICD-10-CM code(s).
- The submitted CPT/HCPCS code must accurately describe the service performed.
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name and dates of service).
Key Coverage Criteria
- Coverage and medical necessity for the 4Kscore test follow Local Coverage Determination L37798; refer to LCD L37798 for specific reasonable and necessary indications.
- Biomarker testing CPT/HCPCS codes for prostate cancer diagnosis are considered medically necessary only when ordered by a physician or other qualified health care professional.
- The ordering provider must be familiar with the proper parameters of use for each specific biomarker test they order.
- 4Kscore testing is covered only when it meets the reasonable and necessary requirements specified in Local Coverage Determination (LCD) L37792.
- 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.
20 Active Policies
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
A59649 — Billing and Coding: MolDX: Proteomics Testing
J05
A56609 — Billing and Coding: Biomarker Testing for Prostate Cancer Diagnosis
J06
A58918 — Billing and Coding: Molecular Pathology and Genetic Testing
J09
A56287
Related Codes
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