Does 99211 require prior authorization?

No, 99211 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 99211?

Medicare facility rate: $7.68. Non-facility rate: $24.38. Work RVU: 0.18.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.18

Facility

$7.68

Non-Facility

$24.38

All documentation requirements for the selected E&M code (history, exam, and medical decision-making per CPT guidelines or time-based criteria) must be met and retained in the medical record.
Documentation should specifically note the evaluation for sleep apnea and the clinical assessment of suitability for an oral appliance to support the medical necessity of the E&M claim.
The IDTF must have Palmetto GBA provider enrollment approval listing the specific CPT/HCPCS codes the facility is authorized to bill for Medicare beneficiaries.
Claims must be supported by documentation showing the supervising and interpreting physicians are licensed in the state(s) of service, enrolled in Medicare, not excluded, and meet any stated proficiency or specialty requirements.

Oral surgeons (Provider Specialty 19) may bill Evaluation & Management (E&M) CPT codes 99202-99215 when evaluating patients with sleep apnea to determine suitability for placement of an oral appliance.
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.

A56006 — Billing and Coding: E&M Coding for Oral Surgeons

A58559 — Billing and Coding: Independent Diagnostic Testing Facilities (IDTF)

A59036 — Billing and Coding: Cognitive Assessment and Care Plan Service

L36593 — Polysomnography

L39266 — Cognitive Assessment and Care Plan Service

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