Does 99454 require prior authorization?

No, 99454 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 99454?

Medicare facility rate: $52.11. Non-facility rate: $52.11. Work RVU: 0.00.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.00

Facility

$52.11

Non-Facility

$52.11

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.
The IDTF enrollment application must list the types of tests (codes) the interpreting physicians and technicians are qualified to interpret or perform.
For services tied to procedure-specific qualifications (e.g., mammography), documentation of facility certifications (e.g., FDA mammography certification) and technician credentials must be maintained and available for claim support.

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.
For each CPT/HCPCS code listed in the policy, the supervising physician and technician must meet the specialty and certification qualifications specified in the policy’s code-to-qualification mapping to be reimbursable by Medicare.

AETNA-CPB-0237 — Chronic Pain Programs

AETNA-CPB-0622 — Glaucoma Testing

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

CIGNA-RPM — Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) - (0563)

ANTHEM-CG-MED-91 — CG-MED-91 Remote Therapeutic and Physiologic Monitoring Services

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