Does Z71.51 require prior authorization?

No, Z71.51 does not require prior authorization (high confidence). Covered without prior authorization.

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`Z71.51`, Drug abuse counseling and surveillance of drug abuser

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.

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.
Presumptive (qualitative) urine drug testing (UDT) is covered when medically necessary to determine presence or absence of drugs or drug classes and when immediate results are needed (point-of-care testing when patient and clinician are co-located).
Definitive quantitative confirmation testing (GC-MS or LC-MS/MS) is covered when medically necessary to identify specific drugs or metabolites not adequately detected by presumptive testing, to distinguish specific drugs within a large drug family, or when a definitive concentration is needed to guide management.
Reflex definitive testing by a reference laboratory is covered without an additional clinician order to verify a presumptive positive UDT or to confirm the absence of a prescribed medication when a laboratory presumptive test is negative.
UDT (presumptive and/or definitive) is covered for symptomatic patients presenting with suspected substance toxicity, including coma, unexplained altered mental status (without a toxidrome), severe or unexplained cardiovascular instability, unexplained metabolic or respiratory acidosis, seizures of undetermined history, or when administration of a specific antagonist is considered.

3 Active Policies

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

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

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

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Z71.51, Drug abuse counseling and surveillance of drug abuser