T76.21XD — Adult sexual abuse, suspected, subsequent encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must fully support medical necessity and include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- For diagnostic tests, report the test result if known; otherwise report the presenting symptoms that prompted the test.
- Providers are exempt from submitting psychotherapy notes without patient authorization when notes meet the Privacy Rule definition in 45 CFR 164.501; the provider is responsible for extracting information required for coverage determinations.
Key Coverage Criteria
- 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.
- CORF social and psychological services are covered when indicated and may be provided by qualified social workers (minimum BS) or psychologists (minimum Master’s level).
- Psychiatric diagnostic procedures may be billed once per day and are covered at the outset of an illness or suspected illness, or again for a new episode after a hiatus or on (re)admission for complications of the underlying condition.
- Psychotherapy codes that include an E/M component are payable when performed by physicians, physician assistants (PA), nurse practitioners (NP), or clinical nurse specialists (CNS) and the E/M component is documented in the record.
- Interactive complexity add-on code 90785 may be reported in conjunction with specified diagnostic and psychotherapy codes when interactive complexity is present.
- 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.
16 Active Policies
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A56937 — Billing and Coding: Psychiatry and Psychology Services
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L33632 — Psychiatry and Psychology Services
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