Does G0500 require prior authorization?

No, G0500 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for G0500?

Medicare facility rate: $5.34. Non-facility rate: $66.47. Work RVU: 0.10.

Verity

`G0500` — Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate)

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.10

Facility

$5.34

Non-Facility

$66.47

Documentation Required

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.

Maintain documentation that additional supplies/agents billed were commonly separately reimbursed to a physician in an office setting when the test is payable.

Physician supervision level (numeric indicators) for each CPT/HCPCS code is defined in the Medicare Physician Fee Schedule Database (MPFSDB) and documentation should reflect the required supervision level for the code billed.

Key Coverage Criteria

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.

2 Active Policies

ANTHEM-CG-MED-21 — CG-MED-21 Anesthesia Services and Moderate (âConsciousâ) Sedation

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

Have a follow-up question?

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