Billing and Coding: Biomarker Testing for Prostate Cancer Diagnosis

Medicare considers biomarker testing CPT/HCPCS codes for prostate cancer diagnosis medically necessary only when ordered by a physician or qualified health professional who is familiar with the test parameters; however, code use does not guarantee coverage. Claims must include a valid ICD-10-CM diagnosis code and, where required, the referring/ordering physician's name and NPI; billing must follow NCCI and OPPS edits and documentation (e.g., clinical guidelines or literature) should support medical necessity.

"Biomarker testing CPT/HCPCS codes for prostate cancer diagnosis are considered medically necessary only when ordered by a physician or other qualified health care professional."

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