Z13.49 — Encounter for screening for other developmental delays
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- For serial assessments or monitoring (e.g., drug efficacy, rehabilitation progress), baseline performance and subsequent test comparisons should be documented.
- Testing should not be performed (and documentation should reflect absence of testing) when the member is actively abusing substances, having acute withdrawal, or recently entered recovery, as results may be invalid.
- A detailed diagnostic evaluation is required prior to NPT/PT (detailed clinical interview, complete history of the test subject and a review of psychological, medical, educational, and other relevant records).
- Testing is covered only when 'the number of hours or units requested for testing does not exceed the reasonable time necessary to address the clinical questions with the identified measures.'
Key Coverage Criteria
- Neuropsychological testing (NPT) when provided to aid in the assessment of cognitive impairment due to medical or psychiatric conditions, when all of the following criteria are met: The number of hours or units requested for testing does not exceed the reasonable time necessary to address the clinical questions with the identified measures; and The testing techniques are validated for the proposed diagnostic question or treatment plan; and The testing techniques do not represent redundant measur [...]
- NPT or PT requested for evaluation of a medical diagnosis (e.g., traumatic brain injury, stroke, differentiation of brain damage from a depressive disorder, epilepsy, hydrocephalus, Alzheimer's disease, Parkinson disease, multiple sclerosis, or AIDS) is considered for coverage under the medical benefit (when selection criteria are met).
- Examples of medically necessary indications for NPT testing include, but are not limited to: Assessment of neurocognitive abilities following traumatic brain injury, stroke, or neurosurgery or relating to a medical diagnosis, such as epilepsy, hydrocephalus or AIDS; Assessment of neurocognitive functions to assist in the development of rehabilitation and/or management strategies for persons with diagnosed neurological disorders; Differential diagnosis between psychogenic and neurogenic syndromes [...]
- NPT or psychological testing (PT) when needed to enhance psychiatric or psychotherapeutic treatment outcomes after a detailed diagnostic evaluation when: Testing is needed to aid in the differential diagnosis of behavioral or psychiatric conditions when the member's history and symptomatology are not readily attributable to a particular psychiatric diagnosis and the questions to be answered by testing could not be resolved by a psychiatric/diagnostic interview, observation in therapy, or an asse [...]
- NPT to distinguish attention deficit/hyperactivity disorder (ADHD) from learning disabilities or language/communication disorders when such distinction remains unclear after history and examination.
- NPT may be considered medically necessary for neurologically complicated cases of ADHD (e.g., post head trauma, seizures).
2 Active Policies
CIGNA-0398 — Transvaginal Ultrasound, Non-Obstetrical - (0398)
AETNA-CPB-0158 — Neuropsychological and Psychological Testing
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