T38.805A — Adverse effect of unspecified hormones and synthetic substitutes, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient's medical record must contain documentation that fully supports 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 code(s) that reflect the patient's condition and indicate the reason(s) the service was performed; claims without ICD-10-CM codes will be returned.
- For diagnostic tests, report the test result on the claim if known; if the result is not known at time of claim, report the symptoms that prompted the test.
- The name and NPI of the referring/ordering physician must be reported on the claim when required by the service.
Key Coverage Criteria
- RAST type tests are covered when medically necessary and supported by the related Local Coverage Determination (LCD) and current medical literature or standards of practice.
- Monitored Anesthesia Care (MAC) is medically necessary when the patient has one or more documented diagnoses listed as supporting medical necessity (e.g., F91.9, G97.81, T81.9XXA, T88.8XXA, F79) and the diagnosis is matched to the anesthesia/CPT/HCPCS procedure performed.
- Use G9 anesthesia modifier to indicate need for MAC due to a history of severe or advanced cardiopulmonary disease when the proceduralist determines additional monitoring is required.
- Use G8 anesthesia modifier for certain deep, complex, complicated, or markedly invasive surgical procedures when applied to anesthesia codes 00100, 00300, 00400, 00160, 00532, or 00920.
- MAC may be appropriate for pediatric patients (Medicare-eligible and younger than 18) when documented using ICD-10-CM code T88.8XXA and clinical records justify the need for MAC.
- Allergy testing is covered when the patient has clinically significant allergic symptoms and conservative therapy has failed.
11 Active Policies
A57472 — Billing and Coding: Allergy Immunotherapy
J05
A57473 — Billing and Coding: Allergy Testing
J05
L36408 — Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)
J05
L36402 — Allergy Testing
J05
L40195 — Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)
Related Codes
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