Does F20.0 require prior authorization?

No, F20.0 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`F20.0`, Paranoid schizophrenia

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

All documentation must be maintained in the patient medical record, be legible, include patient identification and the identity of the physician or non-physician practitioner responsible for care, and be available to the contractor upon request.
Medical record documentation maintained by the ordering/treating physician must indicate the medical necessity and clinical indication(s) that led to ordering the drug test and support the selected diagnosis and CPT/HCPCS code(s).
All tests must be ordered in writing by the treating provider and the order must specify all drugs/drug classes to be tested; the physician’s order must include the clinical indication/medical necessity.
If the performing provider is different from the ordering/referring physician, the performing provider must maintain hard copy documentation of lab results and copies of the ordering physician’s order for the drug test.

Key Coverage Criteria

Urine, blood, or oral fluid specimens may be used for drug testing, with urine preferred for broad screening of common drugs.
Medicare Part B will pay for drug screening services when all coverage criteria, limitations, and medical necessity requirements of LCD DL34645 are met.
Claims for drug screening services are payable under Medicare Part B only in these places of service: office (11), urgent care (20), independent clinic (49), federally qualified health center — freestanding (50), rural health clinic — freestanding (72), and independent laboratory (81).
A psychiatric diagnostic evaluation (CPT 90791) or with medical services (CPT 90792) may be performed once at the onset of an illness or suspected illness.
A psychiatric diagnostic evaluation (90791/90792) may be repeated for the same patient after an extended break (~6 months) in treatment, upon admission to inpatient psychiatric status, for a significant change in mental status, in a patient with established neurological disorder or dementia with acute/marked mental status change, or for a second opinion/diagnostic clarification.
An E/M service may substitute for the initial psychiatric diagnostic interview if all required elements of the E/M billed are fulfilled, including provision of a written opinion and/or advice.

20 Active Policies

CGS-J15-L38394, MolDX: Pharmacogenomics Testing

J15

CGS-J15-L34353, Outpatient Psychiatry and Psychology Services

J15

CGS-J15-L34183, Psychiatric Inpatient Hospitalization

J15

CGS-J15-L34196, Psychiatric Partial Hospitalization Programs

J15

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about F20.0 Sign up free

F20.0, Paranoid schizophrenia