T50.Z95A — Adverse effect of other vaccines and biological substances, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Maintain all documentation in the patient's medical record and make it available to the contractor upon request.
- Every page of the medical record must be legible and include patient identification information (e.g., full 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 submitted medical record must support the selected ICD-10-CM code(s) used for billing.
Key Coverage Criteria
- Allergen immunotherapy is covered only when it meets the reasonable and necessary requirements specified in Local Coverage Determination (LCD) L36240.
- 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.
- 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.
- 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.
20 Active Policies
A57472 — Billing and Coding: Allergy Immunotherapy
J05
L36408 — Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)
J05
L36402 — Allergy Testing
J05
A57473 — Billing and Coding: Allergy Testing
J05
L40195 — Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)
Related Codes
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