Does 81551 require prior authorization?

No, 81551 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 81551?

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

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned as an incomplete claim; the diagnosis code(s) must best describe the patient's condition for which the test was performed.
Providers should reference and document relevant peer-reviewed literature, clinical practice guidelines (e.g., NCCN), or professional society guidance to support medical necessity when applicable.
Billing must comply with any applicable NCCI and OPPS requirements; confirm edits and packaging rules before claim submission.

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.
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).
Molecular biomarker testing to risk-stratify patients at increased risk for prostate cancer when allowed by MolDX Local Coverage Determination L39042.
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.

A58759 — Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate 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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L39042 — MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

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