Does 96131 require prior authorization?

No, 96131 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 96131?

Medicare facility rate: $70.14. Non-facility rate: $86.51. Work RVU: 1.96.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.96

Facility

$70.14

Non-Facility

$86.51

Billing, coding, and required claim documentation must follow the requirements specified in LCD L37633 (see that LCD for required medical records, prior authorization, and claim submission documentation).
Medical record must document medical necessity for services including relevant medical history, physical exam, and pertinent diagnostic test results supporting the LCD indications and limitations.
On admission the physician (MD/DO) must sign a certification that the patient would require inpatient psychiatric hospitalization without PHP and attest that services are furnished under physician care and an individualized written plan of care.
First recertification must be signed by the treating physician on or by the 18th day of PHP and subsequent recertifications must be signed by the treating physician at intervals no less frequently than every 30 days.

Partial Hospitalization Program services that meet the coverage criteria of Local Coverage Determination L37633 are considered covered.
Patient requires active psychiatric partial hospitalization (PHP) with an individualized written plan of care developed by a physician in consultation with appropriate staff and a multidisciplinary team.
Patient requires a minimum of 20 hours per week of therapeutic services as evidenced by the plan of care.
On admission, a physician (MD/DO) certifies that the patient would require inpatient psychiatric hospitalization if PHP services were not provided and attests that services are furnished while the patient is under physician care.
Initial psychiatric evaluation (including medical history and physical examination) is performed and placed in the chart within 48 hours of admission to establish medical necessity.
Diagnosis coding (ICD-10-CM) that best describes the patient's condition is required on the claim to support medical necessity.

A56850 — Billing and Coding: Psychiatric Partial Hospitalization Programs

J06

L33632 — Psychiatry and Psychology Services

J06

A56937 — Billing and Coding: Psychiatry and Psychology Services

J06

L33626 — Psychiatric Partial Hospitalization Programs

J06

A57780

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