T49.6X5A — Adverse effect of otorhinolaryngological drugs and preparations, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- This article provides billing/coding guidelines that complement Local Coverage Determination L34417 for CT of the head; consult LCD L34417 for specific coverage, coding, and documentation requirements.
- 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.
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.
- CPT code 86003 (RAST type test) is covered when billed for diagnostic testing, subject to the stated annual frequency limit.
- Allergy testing for inhalant allergens is covered when medically necessary; evaluation may include up to 90 prick-puncture tests followed by up to 40 intracutaneous tests if prick/puncture results are negative.
- Allergy testing for food sensitivity is covered when medically necessary and may require up to 40 percutaneous tests.
- Multitest intracutaneous testing of up to 60 tests may be appropriate in lieu of prick-puncture testing for selected patients (for example, young children, older adults, or needle-phobic individuals).
- Exceeding the stated testing parameters may be covered when preliminary testing failed and immunotherapy failed to control symptoms, provided documentation supports medical necessity.
19 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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