LCD Reference Article Billing and Coding Article

Billing and Coding: 4Kscore Test Algorithm

A56653

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56653
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: 4Kscore Test Algorithm
Article Type
Billing and Coding
Original Effective Date
12/30/2019
Revision Effective Date
04/29/2024
Revision Ending Date
N/A
Retirement Date
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CMS National Coverage Policy

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Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L37792, 4Kscore Test Algorithm. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

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 must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must 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 the same shall be provided to the performing laboratory prior to the test being performed. A description of the SDM in the patient record containing the patient’s name, provider’s name, date, and legible signature of the provider responsible for providing the care to the patient is considered sufficient documentation of SDM.

Response To Comments

Number Comment Response
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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

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(1 Code)
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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.

The following ICD-10-CM code supports medical necessity and provides coverage for CPT code 81539

Group 1 Codes
Code Description
R97.20 Elevated prostate specific antigen [PSA]
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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-CM Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-PCS Codes

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Group 1 Codes

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Additional ICD-10 Information

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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.

Code Description

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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.

Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
04/29/2024 R2

Article revised and published on 06/06/2024 effective for dates of service on and after 04/29/2024. Documentation Requirement #4 has been updated to remove the requirement of the patient signature related to Shared Decision-Making. This is in response to an inquiry. Minor formatting changes have been made throughout the article.

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.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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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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Public Versions
Updated On Effective Dates Status
05/31/2024 04/29/2024 - N/A Currently in Effect You are here
11/08/2019 12/30/2019 - 04/28/2024 Superseded View
06/21/2019 12/30/2019 - N/A Superseded View

Keywords

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