T63.111A — Toxic effect of venom of gila monster, accidental (unintentional), 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.
- An ECG is covered when the result is relevant to the management, diagnosis, or treatment of the patient.
- A separate ECG on the same day as a cardiac stress test is payable only when it provides additional clinically necessary information beyond the stress test (e.g., to rule out acute myocardial infarction prior to performing the stress test).
- Rhythm ECGs are covered when used to evaluate signs or symptoms suggesting a cardiac rhythm disorder.
- Home-based ECG services (including additional payment above the base ECG amount for transportation) are covered when there is a documented medical need to perform the ECG in the patient's home, typically for homebound or bed-confined patients.
11 Active Policies
A56844 — Billing and Coding: RAST Type Tests
J06
L33591 — RAST Type Tests
J06
L35434 — Oximetry Services
J12
A57205 — Billing and Coding: Oximetry Services
J12
L34315 — Electrocardiograms
Related Codes
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