G11.5 — Hypomyelination - hypogonadotropic hypogonadism - hypodontia
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Required documentation (medical records, evidence of skilled need, teaching/training plans, and physician orders) and any specific forms or certifications are those specified in LCD L34562 and applicable payer guidance.
- Medical records must document for each behavioral disturbance: the specific behavior, frequency, triggers/situations, timing, location, persons involved, alternative explanations (e.g., pain, infection, medication change, swallowing difficulty, catastrophic reaction), consequences, prior successful interventions, and other potential techniques.
- The home health care plan must show that teaching/training interventions are based on the documented assessment, specific impairments and activity limitations, caregiver ability to learn, and environmental factors.
Key Coverage Criteria
- Skilled nursing teaching and training services for beneficiaries diagnosed with Alzheimer's disease or related behavioral disturbances when the services meet the coverage criteria in LCD L34562.
- Medicare home health beneficiaries with Alzheimer's disease and behavioral disturbances are eligible for skilled nursing teaching and training activities to teach family/caregivers how to manage behavioral disturbances.
- Skilled nursing teaching/training must be based on the patient's medical condition in accordance with CMS Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7 §40.1.1.
- Teaching and training interventions must be individualized and based on a full characterization of each behavioral disturbance, identified impairments and activity limitations, the caregiver's ability to learn and implement interventions, and relevant environmental factors.
2 Active Policies
A56641 — Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances
L34562 — Home Health Skilled Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral Disturbances
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.