84154
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- 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.
Key Coverage Criteria
- 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.
- ICD-10 codes listed as covered if selection criteria are met: C61; D07.5; D29.1; D40.0; N40.0 - N40.3; N42.30 - N42.39; R97.20 - R97.21; Z12.5; Z15.03; Z80.42; Z85.46.
- PSA testing for men of all ages with signs or symptoms of prostate cancer.
- Annual PSA screening when used for routine screening in men with previously elevated PSAs or signs or symptoms of disease.
- Prostate-specific antigen (PSA) screening as a preventive service for men 45 years of age and older who are considered average-risk for prostate cancer.
5 Active Policies
A56609 — Billing and Coding: Biomarker Testing for Prostate Cancer Diagnosis
J06
AMBETTER-CG-Onc-Algo-2025.1 — Concert Genetic Oncology: Algorithmic Testing
AETNA-CPB-0521 — Prostate Cancer Screening
CIGNA-A004 — Preventive Care Services - (A004)
HUMANA-EARLY-PROSTATE-CANCER-DETECTION-MA — Early Prostate Cancer Detection - Medicare Advantage
Related Codes
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