Z88.4 — Allergy status to anesthetic agent
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.
- 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.
- Use G8 anesthesia modifier for certain deep, complex, complicated, or markedly invasive surgical procedures when applied to anesthesia codes 00100, 00300, 00400, 00160, 00532, or 00920.
- MAC may be appropriate for pediatric patients (Medicare-eligible and younger than 18) when documented using ICD-10-CM code T88.8XXA and clinical records justify the need for MAC.
12 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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