F09, Unspecified mental disorder due to known physiological condition
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Medical record must contain documentation supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Each claim must be submitted with ICD-10-CM diagnosis code(s) that describe the patient's condition and reasons for the service; claims without a valid ICD-10-CM code will be returned as incomplete.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- If initial assessment or reassessment is completed over multiple encounters, the date of service should be the date the interview was finalized on the claim.
- Advance Beneficiary Notice (ABN) may be used for services likely to be non-covered for medical necessity or other reasons per CMS guidance.
- For physicians, clinical nurse specialists, or nurse practitioners performing these services, use Evaluation & Management or Preventive Medicine codes; services for evaluation/treatment of mental illness should be coded with psychiatric CPT codes (90791-90899) and when both psychiatric and HBAI services are provided, report the predominant service.
Key Coverage Criteria
- Patient has an underlying physical illness or injury for which the HBAI service is intended.
- There is documentation that biopsychosocial factors are significantly affecting treatment or medical management of the illness or injury.
- Patient is alert, oriented, and has capacity to understand and respond meaningfully during a face-to-face encounter.
- There is a documented need for psychological evaluation or intervention to successfully manage the patient's physical illness and activities of daily living.
- The HBAI assessment is not duplicative of other provider assessments.
- Reassessment is reasonable only when documentation shows a sufficient change in mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with medical interventions.
19 Active Policies
CGS-J15-L34353, Outpatient Psychiatry and Psychology Services
J15
CGS-J18-L34353, Outpatient Psychiatry and Psychology Services
J18
A57480, Billing and Coding: Psychiatry and Psychology Services
J5
WPS-J5-L34616, Psychiatry and Psychology Services
J5
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