Does 88313 require prior authorization?

No, 88313 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 88313?

Medicare facility rate: $80.83. Non-facility rate: $80.83. Work RVU: 0.23.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.23

Facility

$80.83

Non-Facility

$80.83

Claims for IHC ER/PR/HER2 must include the appropriate CPT code(s) and unit(s) of service as specified in the policy.
Each billing party (professional and/or technical) is responsible for documenting and justifying the medical necessity of services billed.
Claims for ER, PR, and HER2 IHC must be submitted using the specified CPT codes and unit-of-service values (see frequency section) and be supported by documentation of medical necessity.
Parties submitting professional and/or technical components are each responsible for ensuring and documenting the medical necessity of services billed.

Immunohistochemical (IHC) testing for estrogen receptor (ER), progesterone receptor (PR), and HER2/neu is covered for patients with primary invasive breast cancer.
IHC testing for ER, PR, and HER2/neu is covered for patients with recurrent or metastatic breast cancer.
IHC testing for estrogen receptor (ER) is covered for patients with primary invasive breast cancer and for recurrent or metastatic breast cancer.
IHC testing for progesterone receptor (PR) is covered for patients with primary invasive breast cancer and for recurrent or metastatic breast cancer.
IHC testing for Her-2/neu (HER2) is covered for patients with primary invasive breast cancer and for recurrent or metastatic breast cancer.
IHC testing for estrogen receptor (ER) is covered for patients with primary invasive breast cancer.

L36805 — Lab: Special Histochemical Stains and Immunohistochemical Stains

J05

A57733 — Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains

J05

A57611 — Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains

A57614 — Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains

A59295

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