T38.806A — Underdosing 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
- When E/M services are reported with allergy testing, medical documentation of the separately identifiable E/M service must be present in the medical record and modifier -25 must be used.
- Part B providers must indicate the actual number of tests (one unit per antigen/test) in Box 24G of Form CMS-1500 (paper) or in the service field on EMC claims; the number of tests must also be shown on the claim for MPFSDB payment.
- Medical records must document history (including immunologic history), physical exam, antigens chosen, test performance, and interpretation; counseling and prescriptions should be documented and reported as a visit.
- Hospitals should report charges for single allergy tests as charges per test and bill the appropriate number of units to describe all tests provided, reflecting APC assignment differences (single tests vs multiple tests).
Key Coverage Criteria
- Allergy testing is covered when the patient has clinically significant allergic symptoms and conservative therapy has failed.
- Allergy testing includes performance, evaluation, and reading of cutaneous and mucous membrane tests together with physician history (including immunologic history), physical examination, antigen selection, and interpretation of results.
- Standard skin testing is the preferred method when allergy testing is necessary.
- When a percutaneous or intracutaneous single test (CPT 95004 or 95024) and sequential/incremental tests (CPT 95017, 95018, 95027) are performed the same day, both code types may be reported only if they are for different allergens or for different dilutions of the same allergen.
- CPT code 95060 is payable in office, outpatient hospital (on-campus/off-campus), inpatient hospital, and emergency room settings.
- Allergy skin testing is covered when performed after a complete medical and immunologic history and an appropriate face-to-face physical examination.
5 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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