Does Z13.89 require prior authorization?

No, Z13.89 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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`Z13.89`, Encounter for screening for other disorder

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

When submitting claims, linkage to an appropriate covered ICD-10 diagnosis code (e.g., I50.x for heart failure, J40–J47.x for chronic lower respiratory disease, R06.0x for dyspnea when used to distinguish HF from pulmonary disease) should be documented.
If CPT 83880 is billed, documentation should demonstrate that selection criteria for the covered indications (as stated in the policy) are met (clinical notes, emergency/urgent care evaluation, hospital admission notes, imaging or other cardiac testing as applicable).
For excluded indications (the long list of experimental/investigational uses), documentation supporting those uses will not render services payable — providers should document clinical rationale but should be aware tests for those purposes are considered not medically necessary per policy.

Inferred required documentation to support medical necessity: clinical documentation that demonstrates the indication for testing (e.g., signs/symptoms of dyspnea with differential including heart failure vs pulmonary disease; documentation of chronic heart failure diagnosis and clinical assessment indicating need to determine prognosis or disease severity; hospital admission record indicating acutely decompensated heart failure and intent to use BNP to determine prognosis).

Key Coverage Criteria

Measurement of plasma brain natriuretic peptide (BNP) to differentiate dyspnea due to heart failure from pulmonary disease (i.e., in patients presenting with dyspnea where heart failure versus pulmonary cause is in the differential).
NT-proBNP has certain diagnostic value for pulmonary arterial hypertension (PAH) secondary to systemic sclerosis (SSc-PAH) due to its better specificity and moderate sensitivity.
Measurement of plasma BNP to determine prognosis or disease severity in chronic heart failure.
Measurement of plasma BNP upon hospital admission to determine prognosis in persons with acutely decompensated heart failure.
CPT 83880 (natriuretic peptide) is covered if selection criteria are met (test covered as natriuretic peptide testing).
ICD-10 codes listed as covered diagnoses when selection criteria are met: I50.1 - I50.9 (Heart failure); J40 - J47.9 (Chronic lower respiratory diseases); R06.00 - R06.09 (Dyspnea) [note: dyspnea coverage limited — see limitations]; R06.82 (Tachypnea, not elsewhere classified) [note: coverage limited — see limitations].

8 Active Policies

AMBETTER-CP.MP.97, Testing for Select Genitourinary Conditions

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0029, Thermography

AETNA-CPB-0158, Neuropsychological and Psychological Testing

AETNA-CPB-0306, Laboratory Tests for Depression and Other Psychiatric Disorders

AETNA-CPB-0618, Brain Natriuretic Peptide Testing

AETNA-CPB-0643, Diagnosis of Vaginitis

AETNA-CPB-0650, Polymerase Chain Reaction Testing: Selected Indications

`Z13.89`, Encounter for screening for other disorder

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

Z13.89, Encounter for screening for other disorder

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

`Z13.89`, Encounter for screening for other disorder