R46.5 — Suspiciousness and marked evasiveness
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must meet the reasonable and necessary requirements described in the related LCD (L35101); providers must retain medical record documentation supporting medical necessity per the LCD.
- When billing for services that are not covered, the claim must include the appropriate modifier to indicate non-coverage status.
- When a second provider bills a diagnostic interview for a beneficiary they are seeing for the first time, documentation should support that it is the provider's first encounter with the beneficiary.
- Medical necessity for the diagnostic assessment, psychological/neuropsychological tests, and psychotherapy must be documented in the medical record.
Key Coverage Criteria
- Diagnostic interview codes (e.g., CPT 90791/90792) are indicated for the initial evaluation of a beneficiary, and a second provider seeing the beneficiary for the first time may report diagnostic interview codes for that initial encounter.
- CPT code 96105 is indicated for formal evaluation of aphasia using a standardized instrument (for example, the Boston Diagnostic Aphasia Examination).
- HCPCS codes G0017 and G0018 are appropriate for services provided in non-facility places of service other than Office.
- Diagnostic psychiatric interview is indicated for initial or periodic diagnostic evaluation of a patient with suspected or diagnosed psychiatric illness.
- Additional diagnostic evaluation may be medically reasonable and necessary for the same patient when a new episode of illness occurs, there is an admission or readmission to inpatient status due to complications, or when re-evaluation is required to address a new referral question.
- Interactive diagnostic procedures (e.g., modified interview techniques) are indicated when a patient’s ability to communicate is impaired by expressive or receptive language impairment (hearing loss, deaf mutism, aphasia), language barrier, or lack of mental development (childhood).
2 Active Policies
A57130 — Billing and Coding: Psychiatric Codes
J12
L35101 — Psychiatric Codes
J12
Related Codes
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