Does 86316 require prior authorization?

No, 86316 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 86316?

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

Claims must include the appropriate CPT code (88120 or 88121) and an appropriate ICD-10 diagnosis code supporting the medical necessity.
Laboratories must be CLIA-certified to bill UroVysion™ services and should maintain documentation of CLIA certification in the medical record or billing file.
If only the technical component is billed, the claim must append the TC modifier and documentation must reflect the component performed.
When billing the professional component, the medical record must document that the physician personally read, quantitated, and interpreted the specimen.

FISH bladder tumor marker testing performed using validated assays on urine specimens to monitor for tumor recurrence in patients previously diagnosed with bladder cancer.
FISH bladder tumor marker testing performed using validated assays on urine specimens from persons with hematuria suspected of having bladder cancer to aid initial diagnosis.
Coverage is available for the FDA-approved UroVysion™ Bladder Cancer Kit, which detects aneuploidy of chromosomes 3, 7, and 17 and loss of the 9p21 locus by FISH.
FISH bladder tumor marker testing using a validated assay (e.g., UroVysion) is covered when performed on urine specimens from persons with hematuria suspected of having bladder cancer to aid initial diagnosis.
FISH bladder tumor marker testing using a validated assay (e.g., UroVysion) is covered for monitoring tumor recurrence in patients previously diagnosed with bladder cancer using urine specimens.
FISH bladder tumor marker testing (CPT 88120 or 88121) is covered when performed using validated assays (e.g., UroVysion) on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis.

A56609 — Billing and Coding: Biomarker Testing for Prostate Cancer Diagnosis

J06

A53095 — Billing and Coding: Lab: Bladder/Urothelial Tumor Markers

A55028 — Billing and Coding: Lab: Bladder/Urothelial Tumor Markers

A56471 — Billing and Coding: Bladder/Urothelial Tumor Markers

L36678 — Lab: Bladder/Urothelial Tumor Markers

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