Does R97.20 require prior authorization?

No, R97.20 does not require prior authorization (high confidence). Code is covered without prior authorization.

Verity

`R97.20` — Elevated prostate specific antigen [PSA]

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

The submitted medical record must support the use of the selected ICD-10-CM code(s).
The submitted CPT/HCPCS code must accurately describe the service performed.
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 (e.g., complete name and dates of service).

Key Coverage Criteria

Coverage and medical necessity for the 4Kscore test follow Local Coverage Determination L37798; refer to LCD L37798 for specific reasonable and necessary indications.
4Kscore testing is covered only when it meets the reasonable and necessary requirements specified in Local Coverage Determination (LCD) L37792.
Use these billing and coding instructions when reporting the SelectMDx for Prostate Testing service.
Transrectal ultrasound (TRUS) is covered when it is medically necessary and consistent with the related Local Coverage Determination (LCD) with supporting documentation in the medical record.
Molecular biomarker tests to risk-stratify patients at increased risk for prostate cancer are covered when they meet the clinical indications and medical necessity criteria specified in MolDX LCD L38997.
Molecular biomarker tests to risk-stratify patients at increased risk for prostate cancer are billable when ordered consistent with MolDX LCD L39005.

20 Active Policies

L39042 — MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

J05

A58759 — Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

J05

A57427 — Billing and Coding: Transrectal Ultrasound

J06

L33578 — Transrectal Ultrasound

J06

Have a follow-up question?

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

The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.

Documentation of shared decision-making (SDM) about 4Kscore testing between the ordering provider and patient must be present in the medical record and a copy provided to the performing laboratory prior to the test.

L37798 — 4Kscore Test Algorithm

A56287 — Billing and Coding: 4Kscore Test Algorithm

J09

A59492 — Billing and Coding: Genetic Testing for Oncology

J09

A59491 — Billing and Coding: Genetic Testing for Oncology

J12

L37792 — 4Kscore Test Algorithm

J12

A56653 — Billing and Coding: 4Kscore Test Algorithm

J12

A58713 — Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

A58718 — Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

A58724 — Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

ANTHEM-CG-LAB-28 — CG-LAB-28 Prostate Specific Antigen Testing

A59066 — Billing and Coding: Prostate Cancer Detection with IsoPSA

A57152 — Billing and Coding: MolDX: SelectMDx for Prostate Cancer

L38985 — MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

L39005 — MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

L39007 — MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer

AETNA-CPB-0521 — Prostate Cancer Screening

R97.20 — Elevated prostate specific antigen [PSA]