T45.AX5A — Adverse effect of immune checkpoint inhibitors and immunostimulant drugs, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request; every page must be legible and include appropriate patient identification (e.g., complete name, dates of service).
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- Prior to testing there must be evidence that a history was obtained indicating possible allergy and that attempts were made to narrow the area of investigation so that the minimal necessary skin tests were selected.
Key Coverage Criteria
- Allergy testing is covered when the medical record documents a history indicating the possible presence of allergy and the clinician selected a minimal number of tests/antigens based on patient-specific history and physician examination.
- Allergy testing is covered when the medical record documents the test(s) used, the interpretation(s), and objective measurement of reaction size (wheal and erythema in mm) or a standardized in vivo grading system.
- Cystatin C measurement is covered when performed on an adult (age >=18) patient with a creatinine-based eGFR of 45–59 ml/min/1.73 m2 and who does not have markers of kidney damage.
- Cystatin C measurement is covered when the medical record documents a clear rationale that creatinine-based eGFR estimates are thought to be inaccurate and that more accurate knowledge of GFR will affect clinical decision-making or the patient’s plan of care.
- 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.
10 Active Policies
L36402 — Allergy Testing
J05
A57473 — Billing and Coding: Allergy Testing
J05
L33261 — Allergy Testing
J09
A57531 — Billing and Coding: Allergy Testing
J09
A57657 — Billing and Coding: Sedimentation Rate, Erythrocyte
Related Codes
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