Does F13.139 require prior authorization?

No, F13.139 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`F13.139`, Sedative, hypnotic or anxiolytic abuse with withdrawal, unspecified

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

Medical record must contain documentation supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Each claim must be submitted with ICD-10-CM diagnosis code(s) that describe the patient's condition and reasons for the service; claims without a valid ICD-10-CM code will be returned as incomplete.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

If initial assessment or reassessment is completed over multiple encounters, the date of service should be the date the interview was finalized on the claim.

Advance Beneficiary Notice (ABN) may be used for services likely to be non-covered for medical necessity or other reasons per CMS guidance.

For physicians, clinical nurse specialists, or nurse practitioners performing these services, use Evaluation & Management or Preventive Medicine codes; services for evaluation/treatment of mental illness should be coded with psychiatric CPT codes (90791-90899) and when both psychiatric and HBAI services are provided, report the predominant service.

Key Coverage Criteria

Patient has an underlying physical illness or injury for which the HBAI service is intended.
There is documentation that biopsychosocial factors are significantly affecting treatment or medical management of the illness or injury.
Patient is alert, oriented, and has capacity to understand and respond meaningfully during a face-to-face encounter.
There is a documented need for psychological evaluation or intervention to successfully manage the patient's physical illness and activities of daily living.
The HBAI assessment is not duplicative of other provider assessments.
Reassessment is reasonable only when documentation shows a sufficient change in mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with medical interventions.

17 Active Policies

CGS-J15-L36029, Urine Drug Testing

J15

CGS-J18-L36029, Urine Drug Testing

J18

NGS-J6-L33626, Psychiatric Partial Hospitalization Programs

NGS-J6-L33632, Psychiatry and Psychology Services

A52434, Health and Behavior Assessment/Intervention Medical Policy Article

NGS-J6-L33624, Psychiatric Inpatient Hospitalization

A56850, Billing and Coding: Psychiatric Partial Hospitalization Programs

A56865, Billing and Coding: Psychiatric Inpatient Hospitalization

A56937, Billing and Coding: Psychiatry and Psychology Services

NGS-JK-L33626, Psychiatric Partial Hospitalization Programs

NGS-JK-L33632, Psychiatry and Psychology Services

NGS-JK-L33624, Psychiatric Inpatient Hospitalization

A56818, Billing and Coding: Urine Drug Testing

A56562, Billing and Coding: Health and Behavior Assessment/Intervention

A59718, Billing and Coding: Opioid Treatment Programs

A56614, Billing and Coding: Psychiatric Inpatient Hospitalization

A56756, Billing and Coding: Home Health - Psychiatric Care

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F13.139, Sedative, hypnotic or anxiolytic abuse with withdrawal, unspecified