About this policy
This article contains coding and other guidelines related to Biomarker Testing for Prostate Cancer and is designed to aid in correct billing. Use of the CPT codes below in the CPT/HCPCS section do not guarantee coverage. Specific Coding Information The CPT codes are considered medically necessary when ordered by a physician or other qualified health care professional. The ordering provider must be familiar with the proper parameters of use of each test that they may be ordering. An LCD is not currently available due to the fluid nature of this area of medicine. Coding Information: Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. References Suggested references include peer reviewed literature, compendiums such as NCCN or guidelines from professional organizations or societies.
Documentation requirements
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.