Local Coverage Article Billing and Coding

Billing and Coding: 4Kscore Test Algorithm

A56653

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Contractor Information

Article Information

General Information

Article ID
A56653
Article Title
Billing and Coding: 4Kscore Test Algorithm
Article Type
Billing and Coding
Original Effective Date
12/30/2019
Revision Effective Date
12/30/2019
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

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Article Guidance

Article Text

This article provides coding guidance for the Local Coverage Determination (LCD) L37792 4Kscore Test Algorithm which will become effective on December 30, 2019. Refer to L37792 for reasonable and necessary guidelines.

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
  4. Documentation of shared decision making (SDM) concerning the 4Kscore testing, between the ordering provider and patient, must be present in the medical record and a copy of same shall be provided to the performing laboratory prior to the test being performed.
    • A simple notation that SDM occurred is insufficient for documentation. The actual process must be documented in the patient’s record.
    • The document(s) shall be dated and include the ordering provider and patient’s names and signatures legibly noted to attest that the SDM occurred.

Coding Information

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
CodeDescription
81539 Oncology prostate prob score

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Note: Medicare is establishing the following limited coverage for CPT code 81539

Group 1 Codes
CodeDescription
R97.20 Elevated prostate specific antigen [PSA]

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes
CodeDescription
XX000 Not Applicable

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
999x Not Applicable

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

CodeDescription
99999 Not Applicable

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
12/30/2019 R1

Future billing and coding Article related to L37792, 4Kscore Test Algorithm published on November 14, 2019 and will become effective on December 30, 2019.

Associated Documents

Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/08/2019 12/30/2019 - N/A Currently in Effect You are here
06/21/2019 12/30/2019 - N/A Superseded View

Keywords

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