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ICD-10-CM T43.015A, Adverse effect of tricyclic antidepressants, initial encounter | No Prior Auth

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`T43.015A`, Adverse effect of tricyclic antidepressants, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical necessity for each test must be documented in the patient's medical record as required by LCD L35006.
All documentation must be maintained in the patient's medical record and made available to the contractor upon request; every page must be legible and include patient identification and dates of service.
Documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.

The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.

The patient's medical record must contain documentation that fully supports 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 code(s) that reflect the patient's condition and indicate the reason(s) the service was performed; claims without ICD-10-CM codes will be returned.

Key Coverage Criteria

Urine drug testing (UDT) and drugs-of-abuse testing are covered when reasonable and necessary per LCD L35006 and ordered on an individual patient basis by the treating clinician with medical-record documentation of medical necessity.
Patients with a documented diagnosis consistent with substance use disorder (SUD) may qualify for an exception to the standard presumptive UDT annual limits.
RAST type tests are covered when medically necessary and supported by the related Local Coverage Determination (LCD) and current medical literature or standards of practice.
Monitored Anesthesia Care (MAC) is medically necessary when the patient has one or more documented diagnoses listed as supporting medical necessity (e.g., F91.9, G97.81, T81.9XXA, T88.8XXA, F79) and the diagnosis is matched to the anesthesia/CPT/HCPCS procedure performed.
Use G9 anesthesia modifier to indicate need for MAC due to a history of severe or advanced cardiopulmonary disease when the proceduralist determines additional monitoring is required.
Use G8 anesthesia modifier for certain deep, complex, complicated, or markedly invasive surgical procedures when applied to anesthesia codes 00100, 00300, 00400, 00160, 00532, or 00920.

20 Active Policies

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J15-L34063, RAST Type Tests

J15

CGS-J15-L40325, Allergy Diagnostic Testing

J15

CGS-J18-L40325, Allergy Diagnostic Testing

J18

CGS-J18-L34063, RAST Type Tests

J18

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

WPS-J5-L36402, Allergy Testing

J5

A57473, Billing and Coding: Allergy Testing

J5

A56844, Billing and Coding: RAST Type Tests

J6

NGS-J6-L33591, RAST Type Tests

J6

NGS-J6-L40329, Allergy Diagnostic Testing

J6

WPS-J8-L36402, Allergy Testing

J8

NOVITAS-JH-L35006, Controlled Substance Monitoring and Drugs of Abuse Testing

JH

NOVITAS-JH-L35049, Monitored Anesthesia Care

JH

NGS-JK-L40329, Allergy Diagnostic Testing

JK

NGS-JK-L33591, RAST Type Tests

JK

NOVITAS-JL-L35049, Monitored Anesthesia Care

JL

A57361, Billing and Coding: Monitored Anesthesia Care

JL

NOVITAS-JL-L35006, Controlled Substance Monitoring and Drugs of Abuse Testing

JL

A56645, Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing

JL

Related Codes

T39.2X5A(20 policies)T40.0X5A(20 policies)T39.095A(20 policies)T39.1X5A(20 policies)T39.315A(20 policies)T39.395A(20 policies)T39.015A(20 policies)T40.2X5A(20 policies)

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