Does 96138 require prior authorization?

No, 96138 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 96138?

Medicare facility rate: $37.74. Non-facility rate: $37.74. Work RVU: 0.00.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.00

Facility

$37.74

Non-Facility

$37.74

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.
Recertification must state that without continued PHP the patient would require inpatient psychiatric care and must describe response to interventions, ongoing risk of hospitalization, and treatment goals for discharge coordination.

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.
Psychiatric/psychological services are covered when there is a reasonable expectation that withdrawing treatment would cause the patient's condition to deteriorate, relapse, or require hospitalization.

L34646 — Psychological and Neuropsychological Testing

J05

A57481 — Billing and Coding: Psychological and Neuropsychological Testing

J05

A56937 — Billing and Coding: Psychiatry and Psychology Services

J06

L33626 — Psychiatric Partial Hospitalization Programs

J06

L33632

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