T78.41XA — Arthus phenomenon, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Supportive documentation evidencing the condition and treatment must be documented in the medical record and be available to the Contractor upon request.
- ICD-10-CM diagnosis codes supporting the medical necessity of the service must be submitted with each claim.
- High-utilization or repeat testing should include clinical justification in the record (for example, repeat testing due to unsatisfactory response to treatment) to support medical necessity.
- All documentation supporting MAC must be maintained in the patient's medical record, be legible, include complete patient identification and dates of service, and be made available to the contractor upon request.
Key Coverage Criteria
- 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.
- 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.
- Use G9 anesthesia modifier to indicate need for MAC due to a history of severe or advanced cardiopulmonary disease when the proceduralist determines additional monitoring is required.
4 Active Policies
A57361 — Billing and Coding: Monitored Anesthesia Care
J12
L35049 — Monitored Anesthesia Care
J12
A57181 — Billing and Coding: Allergy Testing
L34313 — Allergy Testing
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.