Does 93016 require prior authorization?

Yes, 93016 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 93016?

Medicare facility rate: $20.71. Non-facility rate: $20.71. Work RVU: 0.44.

HCPCS/CPT

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Work RVU

0.44

Facility

$20.71

Non-Facility

$20.71

All documentation must be maintained in the patient's medical record, be legible, include complete patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
Every submitted medical record page must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
If the service provider differs from the ordering/referring physician, the performing provider must maintain hard copy documentation of test results and interpretation plus copies of the ordering/referring physician’s order for the studies.

Coverage for non-emergent outpatient stress testing is subject to the reasonable and necessary requirements in Local Coverage Determination L35083 and is allowed only when L35083 clinical criteria are met.
For services that require a referring or ordering physician, the claim must report the referring/ordering physician's name and NPI.
Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed; otherwise the claim will be returned as incomplete under SSA Section 1833(e).
For diagnostic tests, the claim should report the test result if known, otherwise report the symptoms that prompted the test.
If a service is likely to be non-covered, an Advance Beneficiary Notice (ABN) may be used and the appropriate modifier (GA, GX, GY, or GZ) should be appended to the claim as applicable.
CPT 78434 (gated SPECT) may be reported only in conjunction with CPT 78431 or CPT 78492 when billed for SPECT myocardial perfusion imaging (MPI).

L38396 — Cardiology Non-emergent Outpatient Stress Testing

J09

L33693 — Peripheral Venous Ultrasound

J09

A56952 — Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing

J09

A56423 — Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing

J12

L35083

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