Does 95957 require prior authorization?

Yes, 95957 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 95957?

Medicare facility rate: $309.96. Non-facility rate: $309.96. Work RVU: 1.93.

HCPCS/CPT

Prior Auth Required

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

Work RVU

1.93

Facility

$309.96

Non-Facility

$309.96

All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (for example, complete name and dates of service).
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
The submitted medical record must support the use of the selected ICD-10-CM code(s).

Special EEG tests are covered only when they meet the reasonable and necessary requirements described in Local Coverage Determination (LCD) L34521.
An IDTF must be credentialed and approved by Palmetto GBA provider enrollment to bill Medicare for a specific diagnostic procedure or material.
Additional services and supplies (e.g., radiopharmaceuticals, special contrast agents, medications) are payable to an IDTF when the diagnostic test itself is payable and the supplies are commonly separately reimbursed to a physician in an office setting.
A supervising physician for an IDTF must be licensed in the state(s) where tests are performed, enrolled in Medicare, not excluded, meet proficiency standards for tests supervised, and provide general supervision for no more than three IDTF sites.
An interpreting physician must be licensed in the state(s) where tests are performed, enrolled in Medicare, not excluded, and qualified to interpret the types of tests (codes) listed on the IDTF enrollment application.
An IDTF technician must meet applicable state licensure and/or certification standards at the time of enrollment and/or at the time tests are performed and be qualified to perform the types of tests (codes) listed in the enrollment application.

L34521 — Special EEG Tests

J09

L33693 — Peripheral Venous Ultrasound

J09

A57667 — Billing and Coding: Special EEG Tests

J09

A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)

J12

L35434 — Oximetry Services

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