Does A4641 require prior authorization?

No, A4641 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for A4641?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`A4641`, Radiopharmaceutical, diagnostic, not otherwise classified

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
When an ABN is used, Form CMS-R-131 must be signed by the beneficiary; for Part A MAC claims include occurrence code 32 and the ABN date on the claim.

Hospital inpatient claims must report the principal diagnosis in UB-04 FL67 and the admitting diagnosis in FL69, with up to eight additional ICD-10-CM codes in FLs 67A-67Q as applicable.

Hospital outpatient claims must report the full ICD-10-CM code for the diagnosis responsible for the outpatient service in UB-04 FL67 and list up to eight other diagnoses in FLs 67A-67Q.

When lymphoscintigraphy is performed in the radiology department prior to surgery, document and code the procedure separately as a radiology service under the appropriate revenue code.

Key Coverage Criteria

Sentinel lymph node biopsy is covered for identification, removal, and pathologic evaluation of sentinel lymph nodes to stage and assess regional lymph node metastasis for malignant tumors.
Preoperative lymphoscintigraphy to locate sentinel node(s) is covered and should be reported separately when performed prior to the surgical procedure.
Injection of radioactive tracer or vital dye for sentinel node localization is covered when performed without lymphoscintigraphy or when performed by the operating surgeon, reported with the appropriate injection code.
Under Medicare Part B, CPT codes 38500, 38510, 38525 and 38530 are payable in inpatient hospital (21), outpatient hospital (22) and ambulatory surgical center (24) places of service.
CPT codes 38792, 38900 and 78195 are payable in office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgical center (24), and independent clinic (49); CPT 78195 global/TC is payable in office (11) and independent clinic (49).
For claims using not otherwise classified (NOC)/unlisted HCPCS codes J3490, J3590, J9999, A4641, or A9699 with limited or specific indications, submit required documentation in the claim remarks field (Field Locator 80 on the UB-04) or the equivalent 5010 electronic claim field so Palmetto GBA can ascertain FDA labeling indications have been met.

5 Active Policies

PALMETTO-JJ-L33457, Cardiac Radionuclide Imaging

PALMETTO-JM-L33457, Cardiac Radionuclide Imaging

A52437, Billing and Coding: Sentinel Lymph Node Biopsy Medical Policy Article

A54880, Billing and Coding: Additional Claim Documentation Requirements for Not Otherwise Classified (NOC) Drugs and Biological Products with Specific FDA Label Indications

A56476, Billing and Coding: Cardiac Radionuclide Imaging

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A4641, Radiopharmaceutical, diagnostic, not otherwise classified