96101
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record documentation of a complete history and physical examination.
- Documented parent/child interview or patient interview containing DSM-5 diagnostic criteria and findings.
- Results of collateral assessments when available (for example, Vanderbilt or Conners questionnaires).
- Psychiatric evaluation report or clinical notes from psychiatrist, psychologist, or other behavioral health professional.
Key Coverage Criteria
- Clinical assessment to establish diagnosis of ADHD in children and adults based on defined clinical parameters.
- Complete medical evaluation with history and physical for assessment/treatment of ADHD.
- Parent/child interview or adult patient interview to obtain DSM-5 diagnostic information for ADHD.
- Collection of collateral information when available (e.g., Vanderbilt or Conners assessments).
- Complete psychiatric evaluation or services provided by a psychiatrist, psychologist, or other behavioral health professional for ADHD assessment/treatment.
- Laboratory evaluation prior to initiation of stimulant medication therapy.
1 Active Policy
AMBETTER-CP.BH.124 — Attention Deficit Hyperactivity Disorder Assessment and Treatment
Related Codes
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