local coverage determination for allergy testing (l34313) · a substitute for skin testing; it is...

Contractor Name Contract Type Contract Number Jurisdiction State(s)Noridian Healthcare Solutions, LLC A and B MAC 01112 - MAC B J - E California - NorthernNoridian Healthcare Solutions, LLC A and B MAC 01182 - MAC B J - E California - Southern

Noridian Healthcare Solutions, LLC A and B MAC 01212 - MAC B J - EAmerican SamoaGuamHawaiiNorthern Mariana Islands

Noridian Healthcare Solutions, LLC A and B MAC 01312 - MAC B J - E Nevada

LCD IDL34313

Original ICD-9 LCD IDL33508

LCD TitleAllergy Testing

AMA CPT / ADA CDT / AHA NUBC Copyright StatementCPT only copyright 2002-2015 American MedicalAssociation. All Rights Reserved. CPT is a registeredtrademark of the American Medical Association.Applicable FARS/DFARS Apply to Government Use. Feeschedules, relative value units, conversion factorsand/or related components are not assigned by theAMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly orindirectly practice medicine or dispense medicalservices. The AMA assumes no liability for datacontained or not contained herein.

The Code on Dental Procedures and Nomenclature(Code) is published in Current Dental Terminology(CDT). Copyright © American Dental Association. Allrights reserved. CDT and CDT-2010 are trademarks ofthe American Dental Association.

Original Effective DateFor services performed on or after 10/01/2015

Revision Effective DateFor services performed on or after 10/01/2015

Revision Ending DateN/A

Retirement DateN/A

Notice Period Start DateN/A

Notice Period End DateN/A

Local Coverage Determination (LCD):Allergy Testing (L34313)

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LCD InformationDocument Information

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https://www.cms.gov/medicare-coverage-database/staticpages/contractor-details.aspx?ContrId=364&ver=1




http://localcoverage.cms.gov/mcd_archive/m_d.asp?id=33508

UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONSMANUAL, 2014, is copyrighted by American HospitalAssociation (“AHA”), Chicago, Illinois. No portion ofOFFICIAL UB-04 MANUAL may be reproduced, sorted ina retrieval system, or transmitted, in any form or byany means, electronic, mechanical, photocopying,recording or otherwise, without prior express, writtenconsent of AHA.” Health Forum reserves the right tochange the copyright notice from time to time uponwritten notice to Company.

• A complete medical and immunologic history and appropriate physical examination must be done prior toperforming diagnostic testing.

• The testing must be performed based on this history and a physical exam, which documents that theantigen being used for testing exists with a reasonable probability of exposure in the patient’senvironment.

• It would not be expected that all patients would receive the same tests or the same number of sensitivitytests. The number of tests performed must be judicious and related to the history, physical findings, andclinical judgment specific to each individual.

CMS National Coverage Policy Title XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicarepayment shall be made for items or services that “are not reasonable and necessary for the diagnosis ortreatment of illness or injury or to improve the functioning of a malformed body member.”

Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations, §411.15, exclude routinephysical examinations.

Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessarydocumentation to process the claim.

CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2,§110.11; food allergy testing and treatment.

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §200; allergy testing andimmunotherapy.

Coverage GuidanceCoverage Indications, Limitations, and/or Medical Necessity

Allergy refers to conditions in which immune responses to environmental antigens cause tissue inflammation andorgan dysfunction. Allergy testing is performed to determine immunologic sensitivity or reaction to antigens forthe purpose of identifying the cause of the allergic state. This policy addresses immediate (IgE-mediated)hypersensitivity and delayed (cell mediated) hypersensitivity. In vivo allergy sensitivity testing correlates theperformance and evaluation of selective cutaneous and mucous membrane tests with the patient's history,physical examination, and other observations. Immediate hypersensitivity may also be tested in vitro bymeasurement of allergen-specific serum IgE. Under certain limited conditions, this is covered by Medicare Part B.Immediate hypersensitivity skin testing is important in the diagnosis of IgE mediated inhalant, food, venom; andpenicillin allergies, delayed hypersensitivity testing is more often helpful in the diagnosis of contact dermatitis andthe clinical evaluation of cell-mediated immunity.

INDICATIONS

Allergy testing is allowed when it has proven efficacy as demonstrated through scientifically valid peer reviewedpublished medical studies.

General Information

In vivo immunologic tests have been shown to be reliable and valid diagnostic tools and include skin tests withstandardized allergenic extracts by prick, puncture, and intradermal techniques, skin end-point titration, andpatch testing.


• Percutaneous Testing remains the test of choice in most clinical situations where immediatehypersensitivity reactions are suspected. Percutaneous tests require medical supervision, since there is asmall but significant risk of anaphylaxis. Overall, skin testing is quick, safe, and cost-effective.

• Intracutaneous/Intradermal Tests are usually performed when increased sensitivity is the main goalsuch as when percutaneous tests (CPT codes 95004 or 95017) are negative and there is a strong suspicionof allergen sensitivity. The usual testing program may include 2 concentrations of an extract: a weakerconcentration and a stronger concentration. It would not be expected that 3 or more concentrations of oneextract would be medically necessary.

• Skin End Point Titration Testing analyzes the highest dilution of a substance that produces a reaction,and may be used to determine the starting dose(s) of allergen immunotherapy.

• Delayed Hypersensitivity Skin Testing has been commonly used in three ways: anergy testing, testingfor infection with intracellular pathogens, and testing for sensitivity to contact allergens. Accurate testingfor contact allergy requires careful attention to technique, and limitation of testing to the specific allergensknown to be associated with a contact reaction.

• Photo Testing is skin irradiation with a specific range of ultraviolet light. Photo tests are performed forthe evaluation of photosensitivity disorders.

• Patch Testing is indicated to evaluate a nonspecific dermatitis, allergic contact dermatitis, pruritus, andother dermatitis to determine the causative antigen.

• Photo Patch Testing uses two patches, with one of them being irradiated with ultraviolet light half waythrough the occlusive period. It is indicated to evaluate unique allergies resulting from light exposure.

• Ophthalmic Mucous Membrane Tests and Direct Nasal Mucous Membrane Tests are rarelyindicated. They are allowed when skin testing cannot test allergens.

• Inhalation Bronchial Challenge Testing involves the inhalation of agents that can trigger respiratoryresponses. The agents include drugs that cause airway constriction, antigens and chemical sensitizersusually related to occupational breathing problems. Pulmonary function studies are not included in thebronchial challenge test. Generally three measures of each determination (e.g., spirometry, prolongedpost exposure evaluation of bronchospasm) are performed. The best of the three is accepted andrepresents one unit of service. A unit is defined as each set of three measurements.

• Ingestion Challenge Test involves the administration of sequentially or incrementally larger doses of thetest item. The test items may include food or antibiotics. The service is allowed once per patientencounter, regardless of the number of items tested, and includes evaluation of the patient's response tothe test items.

• Ingestion challenge food testing performed by the patient in the home, and not in the office setting,will not be covered.

• Provocative testing will be denied as not medically necessary.• Quantitative or semi-quantitative in vitro allergen specific IgE testing (CPT code 86003) is

covered under conditions where skin testing is not possible or is not reliable. In vitro testing is covered asa SUBSTITUTE for skin testing; it is usually not necessary in addition to skin testing. The number of testsdone, frequency of retesting and other coverage issues, are the same as for skin testing. The indicationsfor using in vitro testing instead of in vivo methods must be documented with the claim.

• Qualitative multiallergen screens for allergen specific IgE (CPT code 86005) have insufficientliterature to support clear-cut clinical utility and will be denied as not medically necessary.

• Patients with severe dermatographism, ichthyosis or generalized eczema;• Patients at increased risk for anaphylactic response to skin testing based on clinical history (e.g., when an

unusual allergen is not available as a licensed skin test extract);• Patients unable to discontinue long-acting antihistamines, tricyclic antidepressants, or medications that

may put the patient at undue risk if they are discontinued long enough to perform skin tests;• Patients with mental or physical impairments, who are uncooperative; or• Evaluation of cross-reactivity between insect venoms.

LIMITATIONS

Examples of indications for in vitro testing include the following:


999x Not Applicable

99999 Not Applicable

86003 ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN86005 ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN (DIPSTICK, PADDLE, OR DISK)

95004 PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) WITH ALLERGENIC EXTRACTS, IMMEDIATE TYPEREACTION, INCLUDING TEST INTERPRETATION AND REPORT, SPECIFY NUMBER OF TESTS

95017ALLERGY TESTING, ANY COMBINATION OF PERCUTANEOUS (SCRATCH, PUNCTURE, PRICK) ANDINTRACUTANEOUS (INTRADERMAL), SEQUENTIAL AND INCREMENTAL, WITH VENOMS, IMMEDIATE TYPEREACTION, INCLUDING TEST INTERPRETATION AND REPORT, SPECIFY NUMBER OF TESTS

95018ALLERGY TESTING, ANY COMBINATION OF PERCUTANEOUS (SCRATCH, PUNCTURE, PRICK) ANDINTRACUTANEOUS (INTRADERMAL), SEQUENTIAL AND INCREMENTAL, WITH DRUGS OR BIOLOGICALS,IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT, SPECIFY NUMBER OFTESTS

95024 INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, IMMEDIATE TYPE REACTION,INCLUDING TEST INTERPRETATION AND REPORT, SPECIFY NUMBER OF TESTS

95027INTRACUTANEOUS (INTRADERMAL) TESTS, SEQUENTIAL AND INCREMENTAL, WITH ALLERGENICEXTRACTS FOR AIRBORNE ALLERGENS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATIONAND REPORT, SPECIFY NUMBER OF TESTS

95028 INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, DELAYED TYPE REACTION,INCLUDING READING, SPECIFY NUMBER OF TESTS

95044 PATCH OR APPLICATION TEST(S) (SPECIFY NUMBER OF TESTS)95052 PHOTO PATCH TEST(S) (SPECIFY NUMBER OF TESTS)95056 PHOTO TESTS95060 OPHTHALMIC MUCOUS MEMBRANE TESTS95065 DIRECT NASAL MUCOUS MEMBRANE TEST

95070 INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING NECESSARY PULMONARY FUNCTIONTESTS); WITH HISTAMINE, METHACHOLINE, OR SIMILAR COMPOUNDS

95071 INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING NECESSARY PULMONARY FUNCTIONTESTS); WITH ANTIGENS OR GASES, SPECIFY

95076 INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTION OF TEST ITEMS, EG, FOOD,DRUG OR OTHER SUBSTANCE); INITIAL 120 MINUTES OF TESTING

The following are noncovered antigens: newsprint, tobacco smoke, dandelion, orris root, phenol, alcohol,sugar, yeast, grain mill dust, soybean dust (except when the patient has a known exposure to soybean dust suchas a food processing plant), honeysuckle, fiberglass, green tea, or chalk.

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Coding InformationBill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of allBill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equallyto all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to reportthis service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, servicesreported under other Revenue Codes are equally subject to this coverage determination. Complete absence of allRevenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed toapply equally to all Revenue Codes.

CPT/HCPCS CodesGroup 1 Paragraph: N/A

Group 1 Codes:


95079 INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTION OF TEST ITEMS, EG, FOOD,DRUG OR OTHER SUBSTANCE); EACH ADDITIONAL 60 MINUTES OF TESTING (LIST SEPARATELY INADDITION TO CODE FOR PRIMARY PROCEDURE)

ICD-10Codes Description

H10.411 Chronic giant papillary conjunctivitis, right eyeH10.412 Chronic giant papillary conjunctivitis, left eyeH10.413 Chronic giant papillary conjunctivitis, bilateralH10.45 Other chronic allergic conjunctivitisH65.111 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), right earH65.112 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), left earH65.113 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), bilateralH65.114 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, right earH65.115 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, left earH65.116 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, bilateralH65.194 Other acute nonsuppurative otitis media, recurrent, right earH65.195 Other acute nonsuppurative otitis media, recurrent, left earH65.196 Other acute nonsuppurative otitis media, recurrent, bilateralH65.21 Chronic serous otitis media, right earH65.22 Chronic serous otitis media, left earH65.23 Chronic serous otitis media, bilateralH65.411 Chronic allergic otitis media, right earH65.412 Chronic allergic otitis media, left earH65.413 Chronic allergic otitis media, bilateralH65.491 Other chronic nonsuppurative otitis media, right earH65.492 Other chronic nonsuppurative otitis media, left earH65.493 Other chronic nonsuppurative otitis media, bilateralH68.021 Chronic Eustachian salpingitis, right earH68.022 Chronic Eustachian salpingitis, left earH68.023 Chronic Eustachian salpingitis, bilateralH69.81 Other specified disorders of Eustachian tube, right earH69.82 Other specified disorders of Eustachian tube, left earH69.83 Other specified disorders of Eustachian tube, bilateralJ20.8 Acute bronchitis due to other specified organismsJ30.0 Vasomotor rhinitisJ30.1 Allergic rhinitis due to pollenJ30.2 Other seasonal allergic rhinitisJ30.5 Allergic rhinitis due to foodJ30.81 Allergic rhinitis due to animal (cat) (dog) hair and danderJ30.89 Other allergic rhinitisJ31.0 Chronic rhinitisJ33.0 Polyp of nasal cavityJ33.1 Polypoid sinus degenerationJ33.8 Other polyp of sinusJ33.9 Nasal polyp, unspecifiedJ34.1 Cyst and mucocele of nose and nasal sinusJ34.81 Nasal mucositis (ulcerative)J35.01 Chronic tonsillitisJ35.02 Chronic adenoiditisJ35.03 Chronic tonsillitis and adenoiditisJ35.1 Hypertrophy of tonsilsJ35.2 Hypertrophy of adenoids

ICD-10 Codes that Support Medical NecessityGroup 1 Paragraph: The following list of ICD-10-CM Codes will be covered for CPT Code 86003:

Group 1 Codes:



J35.3 Hypertrophy of tonsils with hypertrophy of adenoidsJ45.20 Mild intermittent asthma, uncomplicatedJ45.21 Mild intermittent asthma with (acute) exacerbationJ45.22 Mild intermittent asthma with status asthmaticusJ45.30 Mild persistent asthma, uncomplicatedJ45.31 Mild persistent asthma with (acute) exacerbationJ45.32 Mild persistent asthma with status asthmaticusJ45.40 Moderate persistent asthma, uncomplicatedJ45.41 Moderate persistent asthma with (acute) exacerbationJ45.42 Moderate persistent asthma with status asthmaticusJ45.50 Severe persistent asthma, uncomplicatedJ45.51 Severe persistent asthma with (acute) exacerbationJ45.52 Severe persistent asthma with status asthmaticusJ45.901 Unspecified asthma with (acute) exacerbationJ45.902 Unspecified asthma with status asthmaticusJ45.909 Unspecified asthma, uncomplicatedJ45.991 Cough variant asthmaJ45.998 Other asthmaL20.0 Besnier's prurigoL20.81 Atopic neurodermatitisL20.82 Flexural eczemaL20.83 Infantile (acute) (chronic) eczemaL20.84 Intrinsic (allergic) eczemaL20.89 Other atopic dermatitisL20.9 Atopic dermatitis, unspecifiedL27.0 Generalized skin eruption due to drugs and medicaments taken internallyL27.1 Localized skin eruption due to drugs and medicaments taken internallyL27.2 Dermatitis due to ingested foodL27.8 Dermatitis due to other substances taken internallyL27.9 Dermatitis due to unspecified substance taken internallyL30.0 Nummular dermatitisL30.2 Cutaneous autosensitizationL30.8 Other specified dermatitisL50.0 Allergic urticariaL50.1 Idiopathic urticariaL50.6 Contact urticariaL50.8 Other urticariaL50.9 Urticaria, unspecifiedR05 CoughR06.00 Dyspnea, unspecifiedR06.02 Shortness of breathR06.09 Other forms of dyspneaR06.2 WheezingR06.9 Unspecified abnormalities of breathingR09.81 Nasal congestionR21 Rash and other nonspecific skin eruptionR43.0 AnosmiaR43.1 ParosmiaR43.2 ParageusiaR43.8 Other disturbances of smell and tasteR43.9 Unspecified disturbances of smell and tasteT36.0X5A Adverse effect of penicillins, initial encounterT36.0X5S Adverse effect of penicillins, sequelaT36.1X5A Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounterT36.1X5S Adverse effect of cephalosporins and other beta-lactam antibiotics, sequelaT36.2X5A Adverse effect of chloramphenicol group, initial encounterT36.2X5S Adverse effect of chloramphenicol group, sequela



T36.3X5A Adverse effect of macrolides, initial encounterT36.3X5S Adverse effect of macrolides, sequelaT36.4X5A Adverse effect of tetracyclines, initial encounterT36.4X5S Adverse effect of tetracyclines, sequelaT36.5X5A Adverse effect of aminoglycosides, initial encounterT36.5X5S Adverse effect of aminoglycosides, sequelaT36.6X5A Adverse effect of rifampicins, initial encounterT36.6X5S Adverse effect of rifampicins, sequelaT36.7X5A Adverse effect of antifungal antibiotics, systemically used, initial encounterT36.7X5S Adverse effect of antifungal antibiotics, systemically used, sequelaT36.8X5A Adverse effect of other systemic antibiotics, initial encounterT36.8X5S Adverse effect of other systemic antibiotics, sequelaT37.0X5A Adverse effect of sulfonamides, initial encounterT37.0X5S Adverse effect of sulfonamides, sequelaT37.1X5A Adverse effect of antimycobacterial drugs, initial encounterT37.1X5S Adverse effect of antimycobacterial drugs, sequelaT37.2X5A Adverse effect of antimalarials and drugs acting on other blood protozoa, initial encounterT37.2X5S Adverse effect of antimalarials and drugs acting on other blood protozoa, sequelaT37.3X5A Adverse effect of other antiprotozoal drugs, initial encounterT37.3X5S Adverse effect of other antiprotozoal drugs, sequelaT37.4X5A Adverse effect of anthelminthics, initial encounterT37.4X5S Adverse effect of anthelminthics, sequelaT37.5X5A Adverse effect of antiviral drugs, initial encounterT38.0X5A Adverse effect of glucocorticoids and synthetic analogues, initial encounterT38.0X5S Adverse effect of glucocorticoids and synthetic analogues, sequelaT38.1X5A Adverse effect of thyroid hormones and substitutes, initial encounterT38.1X5S Adverse effect of thyroid hormones and substitutes, sequelaT38.2X5A Adverse effect of antithyroid drugs, initial encounterT38.2X5S Adverse effect of antithyroid drugs, sequelaT38.3X5A Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounterT38.3X5S Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, sequelaT38.4X5A Adverse effect of oral contraceptives, initial encounterT38.4X5S Adverse effect of oral contraceptives, sequelaT38.5X5A Adverse effect of other estrogens and progestogens, initial encounterT38.5X5S Adverse effect of other estrogens and progestogens, sequela

T38.6X5A Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, initialencounter

T38.6X5S Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified,sequela

T38.7X5A Adverse effect of androgens and anabolic congeners, initial encounterT38.7X5S Adverse effect of androgens and anabolic congeners, sequelaT38.815A Adverse effect of anterior pituitary [adenohypophyseal] hormones, initial encounterT38.815S Adverse effect of anterior pituitary [adenohypophyseal] hormones, sequelaT38.895A Adverse effect of other hormones and synthetic substitutes, initial encounterT38.895S Adverse effect of other hormones and synthetic substitutes, sequelaT38.995A Adverse effect of other hormone antagonists, initial encounterT38.995S Adverse effect of other hormone antagonists, sequelaT39.015A Adverse effect of aspirin, initial encounterT39.015S Adverse effect of aspirin, sequelaT39.095A Adverse effect of salicylates, initial encounterT39.095S Adverse effect of salicylates, sequelaT39.1X5A Adverse effect of 4-Aminophenol derivatives, initial encounterT39.1X5S Adverse effect of 4-Aminophenol derivatives, sequelaT39.2X5A Adverse effect of pyrazolone derivatives, initial encounterT39.2X5S Adverse effect of pyrazolone derivatives, sequelaT39.315A Adverse effect of propionic acid derivatives, initial encounterT39.315S Adverse effect of propionic acid derivatives, sequelaT39.395A Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounterPrinted on 3/2/2016. of 27


T39.395S Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], sequelaT39.4X5A Adverse effect of antirheumatics, not elsewhere classified, initial encounterT39.4X5S Adverse effect of antirheumatics, not elsewhere classified, sequela

T39.8X5A Adverse effect of other nonopioid analgesics and antipyretics, not elsewhere classified, initialencounter

T39.8X5S Adverse effect of other nonopioid analgesics and antipyretics, not elsewhere classified, sequelaT40.0X5A Adverse effect of opium, initial encounterT40.0X5S Adverse effect of opium, sequelaT40.2X5A Adverse effect of other opioids, initial encounterT40.2X5S Adverse effect of other opioids, sequelaT40.3X5A Adverse effect of methadone, initial encounterT40.3X5S Adverse effect of methadone, sequelaT40.4X5A Adverse effect of other synthetic narcotics, initial encounterT40.4X5S Adverse effect of other synthetic narcotics, sequelaT40.5X5A Adverse effect of cocaine, initial encounterT40.5X5S Adverse effect of cocaine, sequelaT40.695A Adverse effect of other narcotics, initial encounterT40.695S Adverse effect of other narcotics, sequelaT40.7X5A Adverse effect of cannabis (derivatives), initial encounterT40.7X5S Adverse effect of cannabis (derivatives), sequelaT40.995A Adverse effect of other psychodysleptics [hallucinogens], initial encounterT40.995S Adverse effect of other psychodysleptics [hallucinogens], sequelaT41.0X5A Adverse effect of inhaled anesthetics, initial encounterT41.0X5S Adverse effect of inhaled anesthetics, sequelaT41.1X5A Adverse effect of intravenous anesthetics, initial encounterT41.1X5S Adverse effect of intravenous anesthetics, sequelaT41.295A Adverse effect of other general anesthetics, initial encounterT41.295S Adverse effect of other general anesthetics, sequelaT41.3X5A Adverse effect of local anesthetics, initial encounterT41.3X5S Adverse effect of local anesthetics, sequelaT41.5X5A Adverse effect of therapeutic gases, initial encounterT41.5X5S Adverse effect of therapeutic gases, sequelaT42.0X5A Adverse effect of hydantoin derivatives, initial encounterT42.0X5S Adverse effect of hydantoin derivatives, sequelaT42.1X5A Adverse effect of iminostilbenes, initial encounterT42.1X5S Adverse effect of iminostilbenes, sequelaT42.2X5A Adverse effect of succinimides and oxazolidinediones, initial encounterT42.2X5S Adverse effect of succinimides and oxazolidinediones, sequelaT42.3X5A Adverse effect of barbiturates, initial encounterT42.4X5A Adverse effect of benzodiazepines, initial encounterT42.4X5S Adverse effect of benzodiazepines, sequelaT42.5X5A Adverse effect of mixed antiepileptics, initial encounterT42.5X5S Adverse effect of mixed antiepileptics, sequelaT42.6X5A Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounterT42.6X5S Adverse effect of other antiepileptic and sedative-hypnotic drugs, sequela

T42.8X5A Adverse effect of antiparkinsonism drugs and other central muscle-tone depressants, initialencounter

T42.8X5S Adverse effect of antiparkinsonism drugs and other central muscle-tone depressants, sequelaT43.015A Adverse effect of tricyclic antidepressants, initial encounterT43.015S Adverse effect of tricyclic antidepressants, sequelaT43.025A Adverse effect of tetracyclic antidepressants, initial encounterT43.025S Adverse effect of tetracyclic antidepressants, sequelaT43.1X5A Adverse effect of monoamine-oxidase-inhibitor antidepressants, initial encounterT43.1X5S Adverse effect of monoamine-oxidase-inhibitor antidepressants, sequelaT43.215A Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounterT43.215S Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, sequelaT43.225A Adverse effect of selective serotonin reuptake inhibitors, initial encounterT43.225S Adverse effect of selective serotonin reuptake inhibitors, sequelaPrinted on 3/2/2016. of 27


T43.295A Adverse effect of other antidepressants, initial encounterT43.295S Adverse effect of other antidepressants, sequelaT43.3X5A Adverse effect of phenothiazine antipsychotics and neuroleptics, initial encounterT43.3X5S Adverse effect of phenothiazine antipsychotics and neuroleptics, sequelaT43.4X5A Adverse effect of butyrophenone and thiothixene neuroleptics, initial encounterT43.4X5S Adverse effect of butyrophenone and thiothixene neuroleptics, sequelaT43.595A Adverse effect of other antipsychotics and neuroleptics, initial encounterT43.595S Adverse effect of other antipsychotics and neuroleptics, sequelaT43.615A Adverse effect of caffeine, initial encounterT43.615S Adverse effect of caffeine, sequelaT43.625A Adverse effect of amphetamines, initial encounterT43.625S Adverse effect of amphetamines, sequelaT43.635A Adverse effect of methylphenidate, initial encounterT43.635S Adverse effect of methylphenidate, sequelaT43.695A Adverse effect of other psychostimulants, initial encounterT43.695S Adverse effect of other psychostimulants, sequelaT43.8X5A Adverse effect of other psychotropic drugs, initial encounterT43.8X5S Adverse effect of other psychotropic drugs, sequelaT44.0X5A Adverse effect of anticholinesterase agents, initial encounterT44.0X5S Adverse effect of anticholinesterase agents, sequelaT44.1X5A Adverse effect of other parasympathomimetics [cholinergics], initial encounterT44.1X5S Adverse effect of other parasympathomimetics [cholinergics], sequelaT44.2X5A Adverse effect of ganglionic blocking drugs, initial encounterT44.2X5S Adverse effect of ganglionic blocking drugs, sequela

T44.3X5A Adverse effect of other parasympatholytics [anticholinergics and antimuscarinics] andspasmolytics, initial encounter

T44.3X5S Adverse effect of other parasympatholytics [anticholinergics and antimuscarinics] andspasmolytics, sequela

T44.4X5A Adverse effect of predominantly alpha-adrenoreceptor agonists, initial encounterT44.4X5S Adverse effect of predominantly alpha-adrenoreceptor agonists, sequelaT44.5X5A Adverse effect of predominantly beta-adrenoreceptor agonists, initial encounterT44.5X5S Adverse effect of predominantly beta-adrenoreceptor agonists, sequelaT44.6X5A Adverse effect of alpha-adrenoreceptor antagonists, initial encounterT44.6X5S Adverse effect of alpha-adrenoreceptor antagonists, sequelaT44.7X5A Adverse effect of beta-adrenoreceptor antagonists, initial encounterT44.7X5S Adverse effect of beta-adrenoreceptor antagonists, sequelaT44.8X5A Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, initial encounterT44.8X5S Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, sequelaT44.995A Adverse effect of other drug primarily affecting the autonomic nervous system, initial encounterT44.995S Adverse effect of other drug primarily affecting the autonomic nervous system, sequelaT45.0X5A Adverse effect of antiallergic and antiemetic drugs, initial encounterT45.0X5S Adverse effect of antiallergic and antiemetic drugs, sequelaT45.1X5A Adverse effect of antineoplastic and immunosuppressive drugs, initial encounterT45.1X5S Adverse effect of antineoplastic and immunosuppressive drugs, sequelaT45.2X5A Adverse effect of vitamins, initial encounterT45.2X5S Adverse effect of vitamins, sequelaT45.3X5A Adverse effect of enzymes, initial encounterT45.3X5S Adverse effect of enzymes, sequelaT45.4X5A Adverse effect of iron and its compounds, initial encounterT45.4X5S Adverse effect of iron and its compounds, sequelaT45.515A Adverse effect of anticoagulants, initial encounterT45.515S Adverse effect of anticoagulants, sequelaT45.525A Adverse effect of antithrombotic drugs, initial encounterT45.525S Adverse effect of antithrombotic drugs, sequelaT45.615A Adverse effect of thrombolytic drugs, initial encounterT45.615S Adverse effect of thrombolytic drugs, sequelaT45.625A Adverse effect of hemostatic drug, initial encounterT45.625S Adverse effect of hemostatic drug, sequelaPrinted on 3/2/2016. of 27


T45.695A Adverse effect of other fibrinolysis-affecting drugs, initial encounterT45.695S Adverse effect of other fibrinolysis-affecting drugs, sequelaT45.7X5A Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, initial encounterT45.7X5S Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, sequelaT45.8X5A Adverse effect of other primarily systemic and hematological agents, initial encounterT45.8X5S Adverse effect of other primarily systemic and hematological agents, sequelaT46.0X5A Adverse effect of cardiac-stimulant glycosides and drugs of similar action, initial encounterT46.0X5S Adverse effect of cardiac-stimulant glycosides and drugs of similar action, sequelaT46.1X5A Adverse effect of calcium-channel blockers, initial encounterT46.1X5S Adverse effect of calcium-channel blockers, sequelaT46.2X5A Adverse effect of other antidysrhythmic drugs, initial encounterT46.2X5S Adverse effect of other antidysrhythmic drugs, sequelaT46.3X5A Adverse effect of coronary vasodilators, initial encounterT46.3X5S Adverse effect of coronary vasodilators, sequelaT46.4X5A Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounterT46.4X5S Adverse effect of angiotensin-converting-enzyme inhibitors, sequelaT46.5X5A Adverse effect of other antihypertensive drugs, initial encounterT46.5X5S Adverse effect of other antihypertensive drugs, sequelaT46.6X5A Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, initial encounterT46.6X5S Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, sequelaT46.7X5A Adverse effect of peripheral vasodilators, initial encounterT46.7X5S Adverse effect of peripheral vasodilators, sequelaT46.8X5A Adverse effect of antivaricose drugs, including sclerosing agents, initial encounterT46.8X5S Adverse effect of antivaricose drugs, including sclerosing agents, sequelaT46.995A Adverse effect of other agents primarily affecting the cardiovascular system, initial encounterT46.995S Adverse effect of other agents primarily affecting the cardiovascular system, sequelaT47.0X5A Adverse effect of histamine H2-receptor blockers, initial encounterT47.0X5S Adverse effect of histamine H2-receptor blockers, sequelaT47.1X5A Adverse effect of other antacids and anti-gastric-secretion drugs, initial encounterT47.1X5S Adverse effect of other antacids and anti-gastric-secretion drugs, sequelaT47.2X5A Adverse effect of stimulant laxatives, initial encounterT47.2X5S Adverse effect of stimulant laxatives, sequelaT47.3X5A Adverse effect of saline and osmotic laxatives, initial encounterT47.3X5S Adverse effect of saline and osmotic laxatives, sequelaT47.4X5A Adverse effect of other laxatives, initial encounterT47.4X5S Adverse effect of other laxatives, sequelaT47.5X5A Adverse effect of digestants, initial encounterT47.5X5S Adverse effect of digestants, sequelaT47.6X5A Adverse effect of antidiarrheal drugs, initial encounterT47.6X5S Adverse effect of antidiarrheal drugs, sequelaT47.7X5A Adverse effect of emetics, initial encounterT47.7X5S Adverse effect of emetics, sequelaT47.8X5A Adverse effect of other agents primarily affecting gastrointestinal system, initial encounterT47.8X5S Adverse effect of other agents primarily affecting gastrointestinal system, sequelaT48.0X5A Adverse effect of oxytocic drugs, initial encounterT48.0X5S Adverse effect of oxytocic drugs, sequelaT48.1X5A Adverse effect of skeletal muscle relaxants [neuromuscular blocking agents], initial encounterT48.1X5S Adverse effect of skeletal muscle relaxants [neuromuscular blocking agents], sequelaT48.295A Adverse effect of other drugs acting on muscles, initial encounterT48.295S Adverse effect of other drugs acting on muscles, sequelaT48.3X5A Adverse effect of antitussives, initial encounterT48.3X5S Adverse effect of antitussives, sequelaT48.4X5A Adverse effect of expectorants, initial encounterT48.4X5S Adverse effect of expectorants, sequelaT48.5X5A Adverse effect of other anti-common-cold drugs, initial encounterT48.5X5S Adverse effect of other anti-common-cold drugs, sequelaT48.6X5A Adverse effect of antiasthmatics, initial encounterT48.6X5S Adverse effect of antiasthmatics, sequelaPrinted on 3/2/2016. of 27


T48.995A Adverse effect of other agents primarily acting on the respiratory system, initial encounterT48.995S Adverse effect of other agents primarily acting on the respiratory system, sequelaT49.0X5A Adverse effect of local antifungal, anti-infective and anti-inflammatory drugs, initial encounterT49.0X5S Adverse effect of local antifungal, anti-infective and anti-inflammatory drugs, sequelaT49.1X5A Adverse effect of antipruritics, initial encounterT49.1X5S Adverse effect of antipruritics, sequelaT49.2X5A Adverse effect of local astringents and local detergents, initial encounterT49.2X5S Adverse effect of local astringents and local detergents, sequelaT49.3X5A Adverse effect of emollients, demulcents and protectants, initial encounterT49.3X5S Adverse effect of emollients, demulcents and protectants, sequela

T49.4X5A Adverse effect of keratolytics, keratoplastics, and other hair treatment drugs and preparations,initial encounter

T49.4X5S Adverse effect of keratolytics, keratoplastics, and other hair treatment drugs and preparations,sequela

T49.5X5A Adverse effect of ophthalmological drugs and preparations, initial encounterT49.5X5S Adverse effect of ophthalmological drugs and preparations, sequelaT49.6X5A Adverse effect of otorhinolaryngological drugs and preparations, initial encounterT49.6X5S Adverse effect of otorhinolaryngological drugs and preparations, sequelaT49.7X5A Adverse effect of dental drugs, topically applied, initial encounterT49.7X5S Adverse effect of dental drugs, topically applied, sequelaT49.8X5A Adverse effect of other topical agents, initial encounterT49.8X5S Adverse effect of other topical agents, sequelaT50.0X5A Adverse effect of mineralocorticoids and their antagonists, initial encounterT50.0X5S Adverse effect of mineralocorticoids and their antagonists, sequelaT50.1X5A Adverse effect of loop [high-ceiling] diuretics, initial encounterT50.1X5S Adverse effect of loop [high-ceiling] diuretics, sequela

T50.2X5A Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initialencounter

T50.2X5S Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, sequelaT50.3X5A Adverse effect of electrolytic, caloric and water-balance agents, initial encounterT50.3X5S Adverse effect of electrolytic, caloric and water-balance agents, sequelaT50.4X5A Adverse effect of drugs affecting uric acid metabolism, initial encounterT50.4X5S Adverse effect of drugs affecting uric acid metabolism, sequelaT50.5X5A Adverse effect of appetite depressants, initial encounterT50.5X5S Adverse effect of appetite depressants, sequelaT50.6X5A Adverse effect of antidotes and chelating agents, initial encounterT50.6X5S Adverse effect of antidotes and chelating agents, sequelaT50.7X5A Adverse effect of analeptics and opioid receptor antagonists, initial encounterT50.7X5S Adverse effect of analeptics and opioid receptor antagonists, sequelaT50.8X5A Adverse effect of diagnostic agents, initial encounterT50.8X5S Adverse effect of diagnostic agents, sequela

T50.A15A Adverse effect of pertussis vaccine, including combinations with a pertussis component, initialencounter

T50.A15S Adverse effect of pertussis vaccine, including combinations with a pertussis component, sequelaT50.A25A Adverse effect of mixed bacterial vaccines without a pertussis component, initial encounterT50.A25S Adverse effect of mixed bacterial vaccines without a pertussis component, sequelaT50.A95A Adverse effect of other bacterial vaccines, initial encounterT50.A95S Adverse effect of other bacterial vaccines, sequelaT50.B15A Adverse effect of smallpox vaccines, initial encounterT50.B15S Adverse effect of smallpox vaccines, sequelaT50.B95A Adverse effect of other viral vaccines, initial encounterT50.B95S Adverse effect of other viral vaccines, sequelaT50.Z15A Adverse effect of immunoglobulin, initial encounterT50.Z15S Adverse effect of immunoglobulin, sequelaT50.Z95A Adverse effect of other vaccines and biological substances, initial encounterT50.Z95S Adverse effect of other vaccines and biological substances, sequelaT50.995A Adverse effect of other drugs, medicaments and biological substances, initial encounterT50.995S Adverse effect of other drugs, medicaments and biological substances, sequela



H10.411 Chronic giant papillary conjunctivitis, right eyeH10.412 Chronic giant papillary conjunctivitis, left eyeH10.413 Chronic giant papillary conjunctivitis, bilateralH10.45 Other chronic allergic conjunctivitisH65.04 Acute serous otitis media, recurrent, right earH65.05 Acute serous otitis media, recurrent, left earH65.06 Acute serous otitis media, recurrent, bilateralH65.111 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), right earH65.112 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), left earH65.113 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), bilateralH65.114 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, right earH65.115 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, left earH65.116 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, bilateralH65.194 Other acute nonsuppurative otitis media, recurrent, right earH65.195 Other acute nonsuppurative otitis media, recurrent, left earH65.196 Other acute nonsuppurative otitis media, recurrent, bilateralH65.21 Chronic serous otitis media, right earH65.22 Chronic serous otitis media, left earH65.23 Chronic serous otitis media, bilateralH65.411 Chronic allergic otitis media, right earH65.412 Chronic allergic otitis media, left earH65.413 Chronic allergic otitis media, bilateralH65.491 Other chronic nonsuppurative otitis media, right earH65.492 Other chronic nonsuppurative otitis media, left earH65.493 Other chronic nonsuppurative otitis media, bilateralH68.021 Chronic Eustachian salpingitis, right earH68.022 Chronic Eustachian salpingitis, left earH68.023 Chronic Eustachian salpingitis, bilateralJ30.0 Vasomotor rhinitisJ30.1 Allergic rhinitis due to pollenJ30.2 Other seasonal allergic rhinitisJ30.5 Allergic rhinitis due to foodJ30.81 Allergic rhinitis due to animal (cat) (dog) hair and danderJ30.89 Other allergic rhinitisJ31.0 Chronic rhinitisJ33.1 Polypoid sinus degenerationJ33.8 Other polyp of sinusJ34.1 Cyst and mucocele of nose and nasal sinusJ34.81 Nasal mucositis (ulcerative)J35.01 Chronic tonsillitisJ35.02 Chronic adenoiditisJ35.03 Chronic tonsillitis and adenoiditisJ35.1 Hypertrophy of tonsilsJ35.2 Hypertrophy of adenoidsJ35.3 Hypertrophy of tonsils with hypertrophy of adenoidsJ44.1 Chronic obstructive pulmonary disease with (acute) exacerbationJ45.20 Mild intermittent asthma, uncomplicatedJ45.21 Mild intermittent asthma with (acute) exacerbationJ45.22 Mild intermittent asthma with status asthmaticusJ45.30 Mild persistent asthma, uncomplicatedJ45.31 Mild persistent asthma with (acute) exacerbationJ45.32 Mild persistent asthma with status asthmaticusJ45.40 Moderate persistent asthma, uncomplicatedJ45.41 Moderate persistent asthma with (acute) exacerbation

Group 2 Paragraph: The following list of ICD-10-CM Codes will be covered for CPT Codes 95004, 95017, 95018,95024, 95027, 95028, 95060, 95065, 95070, 95071, 95076 and 95079:

Group 2 Codes:



J45.42 Moderate persistent asthma with status asthmaticusJ45.50 Severe persistent asthma, uncomplicatedJ45.51 Severe persistent asthma with (acute) exacerbationJ45.52 Severe persistent asthma with status asthmaticusJ45.991 Cough variant asthmaJ45.998 Other asthmaL20.0 Besnier's prurigoL20.81 Atopic neurodermatitisL20.82 Flexural eczemaL20.84 Intrinsic (allergic) eczemaL20.89 Other atopic dermatitisL27.0 Generalized skin eruption due to drugs and medicaments taken internallyL27.1 Localized skin eruption due to drugs and medicaments taken internallyL27.2 Dermatitis due to ingested foodL27.8 Dermatitis due to other substances taken internallyL29.9 Pruritus, unspecifiedL50.0 Allergic urticariaL50.1 Idiopathic urticariaL50.6 Contact urticariaL50.8 Other urticariaL50.9 Urticaria, unspecifiedR05 CoughR06.02 Shortness of breathR06.2 WheezingR09.81 Nasal congestionR21 Rash and other nonspecific skin eruptionR23.8 Other skin changesR23.9 Unspecified skin changesR43.0 AnosmiaR43.1 ParosmiaR43.2 ParageusiaR43.8 Other disturbances of smell and tasteR43.9 Unspecified disturbances of smell and tasteT36.0X5A Adverse effect of penicillins, initial encounterT36.0X5S Adverse effect of penicillins, sequelaT36.1X5A Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounterT36.1X5S Adverse effect of cephalosporins and other beta-lactam antibiotics, sequelaT36.2X5A Adverse effect of chloramphenicol group, initial encounterT36.2X5S Adverse effect of chloramphenicol group, sequelaT36.3X5A Adverse effect of macrolides, initial encounterT36.3X5S Adverse effect of macrolides, sequelaT36.4X5A Adverse effect of tetracyclines, initial encounterT36.4X5S Adverse effect of tetracyclines, sequelaT36.5X5A Adverse effect of aminoglycosides, initial encounterT36.5X5S Adverse effect of aminoglycosides, sequelaT36.6X5A Adverse effect of rifampicins, initial encounterT36.6X5S Adverse effect of rifampicins, sequelaT36.7X5A Adverse effect of antifungal antibiotics, systemically used, initial encounterT36.7X5S Adverse effect of antifungal antibiotics, systemically used, sequelaT36.8X5A Adverse effect of other systemic antibiotics, initial encounterT36.8X5S Adverse effect of other systemic antibiotics, sequelaT37.0X5A Adverse effect of sulfonamides, initial encounterT37.0X5S Adverse effect of sulfonamides, sequelaT37.1X5A Adverse effect of antimycobacterial drugs, initial encounterT37.1X5S Adverse effect of antimycobacterial drugs, sequelaT37.2X5A Adverse effect of antimalarials and drugs acting on other blood protozoa, initial encounterT37.2X5S Adverse effect of antimalarials and drugs acting on other blood protozoa, sequelaT37.3X5A Adverse effect of other antiprotozoal drugs, initial encounterPrinted on 3/2/2016. of 27


T37.3X5S Adverse effect of other antiprotozoal drugs, sequelaT37.4X5A Adverse effect of anthelminthics, initial encounterT37.4X5S Adverse effect of anthelminthics, sequelaT37.5X5A Adverse effect of antiviral drugs, initial encounterT37.5X5S Adverse effect of antiviral drugs, sequelaT38.0X5A Adverse effect of glucocorticoids and synthetic analogues, initial encounterT38.0X5S Adverse effect of glucocorticoids and synthetic analogues, sequelaT38.1X5A Adverse effect of thyroid hormones and substitutes, initial encounterT38.1X5S Adverse effect of thyroid hormones and substitutes, sequelaT38.2X5A Adverse effect of antithyroid drugs, initial encounterT38.2X5S Adverse effect of antithyroid drugs, sequelaT38.3X5A Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounterT38.3X5S Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, sequelaT38.4X5A Adverse effect of oral contraceptives, initial encounterT38.4X5S Adverse effect of oral contraceptives, sequelaT38.5X5A Adverse effect of other estrogens and progestogens, initial encounterT38.5X5S Adverse effect of other estrogens and progestogens, sequela



T38.7X5A Adverse effect of androgens and anabolic congeners, initial encounterT38.7X5S Adverse effect of androgens and anabolic congeners, sequelaT38.815A Adverse effect of anterior pituitary [adenohypophyseal] hormones, initial encounterT38.815S Adverse effect of anterior pituitary [adenohypophyseal] hormones, sequelaT38.895A Adverse effect of other hormones and synthetic substitutes, initial encounterT38.895S Adverse effect of other hormones and synthetic substitutes, sequelaT38.995A Adverse effect of other hormone antagonists, initial encounterT38.995S Adverse effect of other hormone antagonists, sequelaT39.015A Adverse effect of aspirin, initial encounterT39.015S Adverse effect of aspirin, sequelaT39.095A Adverse effect of salicylates, initial encounterT39.095S Adverse effect of salicylates, sequelaT39.1X5A Adverse effect of 4-Aminophenol derivatives, initial encounterT39.1X5S Adverse effect of 4-Aminophenol derivatives, sequelaT39.2X5A Adverse effect of pyrazolone derivatives, initial encounterT39.2X5S Adverse effect of pyrazolone derivatives, sequelaT39.315A Adverse effect of propionic acid derivatives, initial encounterT39.315S Adverse effect of propionic acid derivatives, sequelaT39.395A Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounterT39.395S Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], sequelaT39.4X5A Adverse effect of antirheumatics, not elsewhere classified, initial encounterT39.4X5S Adverse effect of antirheumatics, not elsewhere classified, sequela


T39.8X5S Adverse effect of other nonopioid analgesics and antipyretics, not elsewhere classified, sequelaT40.0X5A Adverse effect of opium, initial encounterT40.0X5S Adverse effect of opium, sequelaT40.2X5A Adverse effect of other opioids, initial encounterT40.2X5S Adverse effect of other opioids, sequelaT40.3X5A Adverse effect of methadone, initial encounterT40.3X5S Adverse effect of methadone, sequelaT40.4X5A Adverse effect of other synthetic narcotics, initial encounterT40.4X5S Adverse effect of other synthetic narcotics, sequelaT40.5X5A Adverse effect of cocaine, initial encounterT40.5X5S Adverse effect of cocaine, sequelaT40.695A Adverse effect of other narcotics, initial encounterT40.695S Adverse effect of other narcotics, sequelaPrinted on 3/2/2016. of 27


T40.7X5A Adverse effect of cannabis (derivatives), initial encounterT40.7X5S Adverse effect of cannabis (derivatives), sequelaT40.995A Adverse effect of other psychodysleptics [hallucinogens], initial encounterT40.995S Adverse effect of other psychodysleptics [hallucinogens], sequelaT41.0X5A Adverse effect of inhaled anesthetics, initial encounterT41.0X5S Adverse effect of inhaled anesthetics, sequelaT41.1X5A Adverse effect of intravenous anesthetics, initial encounterT41.1X5S Adverse effect of intravenous anesthetics, sequelaT41.295A Adverse effect of other general anesthetics, initial encounterT41.295S Adverse effect of other general anesthetics, sequelaT41.3X5A Adverse effect of local anesthetics, initial encounterT41.3X5S Adverse effect of local anesthetics, sequelaT41.5X5A Adverse effect of therapeutic gases, initial encounterT41.5X5S Adverse effect of therapeutic gases, sequelaT42.0X5A Adverse effect of hydantoin derivatives, initial encounterT42.0X5S Adverse effect of hydantoin derivatives, sequelaT42.1X5A Adverse effect of iminostilbenes, initial encounterT42.1X5S Adverse effect of iminostilbenes, sequelaT42.2X5A Adverse effect of succinimides and oxazolidinediones, initial encounterT42.2X5S Adverse effect of succinimides and oxazolidinediones, sequelaT42.3X5A Adverse effect of barbiturates, initial encounterT42.3X5S Adverse effect of barbiturates, sequelaT42.4X5A Adverse effect of benzodiazepines, initial encounterT42.4X5S Adverse effect of benzodiazepines, sequelaT42.5X5A Adverse effect of mixed antiepileptics, initial encounterT42.5X5S Adverse effect of mixed antiepileptics, sequelaT42.6X5A Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounterT42.6X5S Adverse effect of other antiepileptic and sedative-hypnotic drugs, sequela


T42.8X5S Adverse effect of antiparkinsonism drugs and other central muscle-tone depressants, sequelaT43.015A Adverse effect of tricyclic antidepressants, initial encounterT43.015S Adverse effect of tricyclic antidepressants, sequelaT43.025A Adverse effect of tetracyclic antidepressants, initial encounterT43.025S Adverse effect of tetracyclic antidepressants, sequelaT43.1X5A Adverse effect of monoamine-oxidase-inhibitor antidepressants, initial encounterT43.1X5S Adverse effect of monoamine-oxidase-inhibitor antidepressants, sequelaT43.215A Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounterT43.215S Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, sequelaT43.225A Adverse effect of selective serotonin reuptake inhibitors, initial encounterT43.225S Adverse effect of selective serotonin reuptake inhibitors, sequelaT43.295A Adverse effect of other antidepressants, initial encounterT43.295S Adverse effect of other antidepressants, sequelaT43.3X5A Adverse effect of phenothiazine antipsychotics and neuroleptics, initial encounterT43.3X5S Adverse effect of phenothiazine antipsychotics and neuroleptics, sequelaT43.4X5A Adverse effect of butyrophenone and thiothixene neuroleptics, initial encounterT43.4X5S Adverse effect of butyrophenone and thiothixene neuroleptics, sequelaT43.595A Adverse effect of other antipsychotics and neuroleptics, initial encounterT43.595S Adverse effect of other antipsychotics and neuroleptics, sequelaT43.615A Adverse effect of caffeine, initial encounterT43.615S Adverse effect of caffeine, sequelaT43.625A Adverse effect of amphetamines, initial encounterT43.625S Adverse effect of amphetamines, sequelaT43.635A Adverse effect of methylphenidate, initial encounterT43.635S Adverse effect of methylphenidate, sequelaT43.695A Adverse effect of other psychostimulants, initial encounterT43.695S Adverse effect of other psychostimulants, sequelaT43.8X5A Adverse effect of other psychotropic drugs, initial encounterPrinted on 3/2/2016. of 27


T43.8X5S Adverse effect of other psychotropic drugs, sequelaT44.0X5A Adverse effect of anticholinesterase agents, initial encounterT44.0X5S Adverse effect of anticholinesterase agents, sequelaT44.1X5A Adverse effect of other parasympathomimetics [cholinergics], initial encounterT44.1X5S Adverse effect of other parasympathomimetics [cholinergics], sequelaT44.2X5A Adverse effect of ganglionic blocking drugs, initial encounterT44.2X5S Adverse effect of ganglionic blocking drugs, sequela



T44.4X5A Adverse effect of predominantly alpha-adrenoreceptor agonists, initial encounterT44.4X5S Adverse effect of predominantly alpha-adrenoreceptor agonists, sequelaT44.5X5A Adverse effect of predominantly beta-adrenoreceptor agonists, initial encounterT44.5X5S Adverse effect of predominantly beta-adrenoreceptor agonists, sequelaT44.6X5A Adverse effect of alpha-adrenoreceptor antagonists, initial encounterT44.6X5S Adverse effect of alpha-adrenoreceptor antagonists, sequelaT44.7X5A Adverse effect of beta-adrenoreceptor antagonists, initial encounterT44.7X5S Adverse effect of beta-adrenoreceptor antagonists, sequelaT44.8X5A Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, initial encounterT44.8X5S Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, sequelaT44.995A Adverse effect of other drug primarily affecting the autonomic nervous system, initial encounterT44.995S Adverse effect of other drug primarily affecting the autonomic nervous system, sequelaT45.0X5A Adverse effect of antiallergic and antiemetic drugs, initial encounterT45.0X5S Adverse effect of antiallergic and antiemetic drugs, sequelaT45.1X5A Adverse effect of antineoplastic and immunosuppressive drugs, initial encounterT45.1X5S Adverse effect of antineoplastic and immunosuppressive drugs, sequelaT45.2X5A Adverse effect of vitamins, initial encounterT45.2X5S Adverse effect of vitamins, sequelaT45.3X5A Adverse effect of enzymes, initial encounterT45.3X5S Adverse effect of enzymes, sequelaT45.4X5A Adverse effect of iron and its compounds, initial encounterT45.4X5S Adverse effect of iron and its compounds, sequelaT45.515A Adverse effect of anticoagulants, initial encounterT45.515S Adverse effect of anticoagulants, sequelaT45.525A Adverse effect of antithrombotic drugs, initial encounterT45.525S Adverse effect of antithrombotic drugs, sequelaT45.615A Adverse effect of thrombolytic drugs, initial encounterT45.615S Adverse effect of thrombolytic drugs, sequelaT45.625A Adverse effect of hemostatic drug, initial encounterT45.625S Adverse effect of hemostatic drug, sequelaT45.695A Adverse effect of other fibrinolysis-affecting drugs, initial encounterT45.695S Adverse effect of other fibrinolysis-affecting drugs, sequelaT45.7X5A Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, initial encounterT45.7X5S Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, sequelaT45.8X5A Adverse effect of other primarily systemic and hematological agents, initial encounterT45.8X5S Adverse effect of other primarily systemic and hematological agents, sequelaT46.0X5A Adverse effect of cardiac-stimulant glycosides and drugs of similar action, initial encounterT46.0X5S Adverse effect of cardiac-stimulant glycosides and drugs of similar action, sequelaT46.1X5A Adverse effect of calcium-channel blockers, initial encounterT46.1X5S Adverse effect of calcium-channel blockers, sequelaT46.2X5A Adverse effect of other antidysrhythmic drugs, initial encounterT46.2X5S Adverse effect of other antidysrhythmic drugs, sequelaT46.3X5A Adverse effect of coronary vasodilators, initial encounterT46.3X5S Adverse effect of coronary vasodilators, sequelaT46.4X5A Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounterT46.4X5S Adverse effect of angiotensin-converting-enzyme inhibitors, sequelaT46.5X5A Adverse effect of other antihypertensive drugs, initial encounterPrinted on 3/2/2016. of 27


T46.5X5S Adverse effect of other antihypertensive drugs, sequelaT46.6X5A Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, initial encounterT46.6X5S Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, sequelaT46.7X5A Adverse effect of peripheral vasodilators, initial encounterT46.7X5S Adverse effect of peripheral vasodilators, sequelaT46.8X5A Adverse effect of antivaricose drugs, including sclerosing agents, initial encounterT46.8X5S Adverse effect of antivaricose drugs, including sclerosing agents, sequelaT46.995A Adverse effect of other agents primarily affecting the cardiovascular system, initial encounterT46.995S Adverse effect of other agents primarily affecting the cardiovascular system, sequelaT47.0X5A Adverse effect of histamine H2-receptor blockers, initial encounterT47.0X5S Adverse effect of histamine H2-receptor blockers, sequelaT47.1X5A Adverse effect of other antacids and anti-gastric-secretion drugs, initial encounterT47.1X5S Adverse effect of other antacids and anti-gastric-secretion drugs, sequelaT47.2X5A Adverse effect of stimulant laxatives, initial encounterT47.2X5S Adverse effect of stimulant laxatives, sequelaT47.3X5A Adverse effect of saline and osmotic laxatives, initial encounterT47.3X5S Adverse effect of saline and osmotic laxatives, sequelaT47.4X5A Adverse effect of other laxatives, initial encounterT47.4X5S Adverse effect of other laxatives, sequelaT47.5X5A Adverse effect of digestants, initial encounterT47.5X5S Adverse effect of digestants, sequelaT47.6X5A Adverse effect of antidiarrheal drugs, initial encounterT47.6X5S Adverse effect of antidiarrheal drugs, sequelaT47.7X5A Adverse effect of emetics, initial encounterT47.7X5S Adverse effect of emetics, sequelaT47.8X5A Adverse effect of other agents primarily affecting gastrointestinal system, initial encounterT47.8X5S Adverse effect of other agents primarily affecting gastrointestinal system, sequelaT48.0X5A Adverse effect of oxytocic drugs, initial encounterT48.0X5S Adverse effect of oxytocic drugs, sequelaT48.1X5A Adverse effect of skeletal muscle relaxants [neuromuscular blocking agents], initial encounterT48.1X5S Adverse effect of skeletal muscle relaxants [neuromuscular blocking agents], sequelaT48.295A Adverse effect of other drugs acting on muscles, initial encounterT48.295S Adverse effect of other drugs acting on muscles, sequelaT48.3X5A Adverse effect of antitussives, initial encounterT48.3X5S Adverse effect of antitussives, sequelaT48.4X5A Adverse effect of expectorants, initial encounterT48.4X5S Adverse effect of expectorants, sequelaT48.5X5A Adverse effect of other anti-common-cold drugs, initial encounterT48.5X5S Adverse effect of other anti-common-cold drugs, sequelaT48.6X5A Adverse effect of antiasthmatics, initial encounterT48.6X5S Adverse effect of antiasthmatics, sequelaT48.995A Adverse effect of other agents primarily acting on the respiratory system, initial encounterT48.995S Adverse effect of other agents primarily acting on the respiratory system, sequelaT49.0X5A Adverse effect of local antifungal, anti-infective and anti-inflammatory drugs, initial encounterT49.0X5S Adverse effect of local antifungal, anti-infective and anti-inflammatory drugs, sequelaT49.1X5A Adverse effect of antipruritics, initial encounterT49.1X5S Adverse effect of antipruritics, sequelaT49.2X5A Adverse effect of local astringents and local detergents, initial encounterT49.2X5S Adverse effect of local astringents and local detergents, sequelaT49.3X5A Adverse effect of emollients, demulcents and protectants, initial encounterT49.3X5S Adverse effect of emollients, demulcents and protectants, sequela



T49.5X5A Adverse effect of ophthalmological drugs and preparations, initial encounterT49.5X5S Adverse effect of ophthalmological drugs and preparations, sequelaT49.6X5A Adverse effect of otorhinolaryngological drugs and preparations, initial encounterPrinted on 3/2/2016. of 27


T49.6X5S Adverse effect of otorhinolaryngological drugs and preparations, sequelaT49.7X5A Adverse effect of dental drugs, topically applied, initial encounterT49.7X5S Adverse effect of dental drugs, topically applied, sequelaT49.8X5A Adverse effect of other topical agents, initial encounterT49.8X5S Adverse effect of other topical agents, sequelaT50.0X5A Adverse effect of mineralocorticoids and their antagonists, initial encounterT50.0X5S Adverse effect of mineralocorticoids and their antagonists, sequelaT50.1X5A Adverse effect of loop [high-ceiling] diuretics, initial encounterT50.1X5S Adverse effect of loop [high-ceiling] diuretics, sequela




T50.A15S Adverse effect of pertussis vaccine, including combinations with a pertussis component, sequelaT50.A25A Adverse effect of mixed bacterial vaccines without a pertussis component, initial encounterT50.A25S Adverse effect of mixed bacterial vaccines without a pertussis component, sequelaT50.A95A Adverse effect of other bacterial vaccines, initial encounterT50.A95S Adverse effect of other bacterial vaccines, sequelaT50.B15A Adverse effect of smallpox vaccines, initial encounterT50.B15S Adverse effect of smallpox vaccines, sequelaT50.B95A Adverse effect of other viral vaccines, initial encounterT50.B95S Adverse effect of other viral vaccines, sequelaT50.Z15A Adverse effect of immunoglobulin, initial encounterT50.Z15S Adverse effect of immunoglobulin, sequelaT50.Z95A Adverse effect of other vaccines and biological substances, initial encounterT50.Z95S Adverse effect of other vaccines and biological substances, sequelaT50.995A Adverse effect of other drugs, medicaments and biological substances, initial encounterT50.995S Adverse effect of other drugs, medicaments and biological substances, sequelaT78.01XA Anaphylactic reaction due to peanuts, initial encounterT78.01XS Anaphylactic reaction due to peanuts, sequelaT78.02XA Anaphylactic reaction due to shellfish (crustaceans), initial encounterT78.02XS Anaphylactic reaction due to shellfish (crustaceans), sequelaT78.03XA Anaphylactic reaction due to other fish, initial encounterT78.03XS Anaphylactic reaction due to other fish, sequelaT78.04XA Anaphylactic reaction due to fruits and vegetables, initial encounterT78.04XS Anaphylactic reaction due to fruits and vegetables, sequelaT78.05XA Anaphylactic reaction due to tree nuts and seeds, initial encounterT78.05XS Anaphylactic reaction due to tree nuts and seeds, sequelaT78.06XA Anaphylactic reaction due to food additives, initial encounterT78.06XS Anaphylactic reaction due to food additives, sequelaT78.07XA Anaphylactic reaction due to milk and dairy products, initial encounterT78.07XS Anaphylactic reaction due to milk and dairy products, sequelaT78.08XA Anaphylactic reaction due to eggs, initial encounterT78.08XS Anaphylactic reaction due to eggs, sequelaT78.09XA Anaphylactic reaction due to other food products, initial encounterPrinted on 3/2/2016. of 27


T78.09XS Anaphylactic reaction due to other food products, sequelaT78.1XXA Other adverse food reactions, not elsewhere classified, initial encounterT78.1XXS Other adverse food reactions, not elsewhere classified, sequelaT78.3XXA Angioneurotic edema, initial encounterT78.3XXS Angioneurotic edema, sequelaT78.41XA Arthus phenomenon, initial encounterT78.41XS Arthus phenomenon, sequelaT78.49XA Other allergy, initial encounterT78.49XS Other allergy, sequelaT88.2XXA Shock due to anesthesia, initial encounterT88.2XXS Shock due to anesthesia, sequelaT88.59XA Other complications of anesthesia, initial encounterT88.59XS Other complications of anesthesia, sequela

T88.6XXA Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered,initial encounter

T88.6XXS Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered,sequela

ICD-10 Codes DescriptionE80.0 Hereditary erythropoietic porphyriaE80.1 Porphyria cutanea tardaE80.21 Acute intermittent (hepatic) porphyriaE80.29 Other porphyriaL20.0 Besnier's prurigoL20.81 Atopic neurodermatitisL20.82 Flexural eczemaL20.84 Intrinsic (allergic) eczemaL20.89 Other atopic dermatitisL23.0 Allergic contact dermatitis due to metalsL23.1 Allergic contact dermatitis due to adhesivesL23.2 Allergic contact dermatitis due to cosmeticsL23.3 Allergic contact dermatitis due to drugs in contact with skinL23.4 Allergic contact dermatitis due to dyesL23.5 Allergic contact dermatitis due to other chemical productsL23.6 Allergic contact dermatitis due to food in contact with the skinL23.7 Allergic contact dermatitis due to plants, except foodL23.81 Allergic contact dermatitis due to animal (cat) (dog) danderL23.89 Allergic contact dermatitis due to other agentsL24.0 Irritant contact dermatitis due to detergentsL24.1 Irritant contact dermatitis due to oils and greasesL24.2 Irritant contact dermatitis due to solventsL24.3 Irritant contact dermatitis due to cosmeticsL24.4 Irritant contact dermatitis due to drugs in contact with skinL24.5 Irritant contact dermatitis due to other chemical productsL24.6 Irritant contact dermatitis due to food in contact with skinL24.7 Irritant contact dermatitis due to plants, except foodL24.81 Irritant contact dermatitis due to metalsL24.89 Irritant contact dermatitis due to other agentsL24.9 Irritant contact dermatitis, unspecified causeL25.0 Unspecified contact dermatitis due to cosmeticsL25.1 Unspecified contact dermatitis due to drugs in contact with skinL25.2 Unspecified contact dermatitis due to dyesL25.3 Unspecified contact dermatitis due to other chemical products

Group 3 Paragraph: The following list of ICD-10-CM Codes will be covered for CPT Codes 95044, 95052, and95056:

Group 3 Codes:


ICD-10 Codes DescriptionL25.4 Unspecified contact dermatitis due to food in contact with skinL25.5 Unspecified contact dermatitis due to plants, except foodL25.8 Unspecified contact dermatitis due to other agentsL25.9 Unspecified contact dermatitis, unspecified causeL26 Exfoliative dermatitisL30.0 Nummular dermatitisL30.1 Dyshidrosis [pompholyx]L30.2 Cutaneous autosensitizationL30.4 Erythema intertrigoL30.8 Other specified dermatitisL30.9 Dermatitis, unspecifiedL50.6 Contact urticariaL53.8 Other specified erythematous conditionsL54 Erythema in diseases classified elsewhereL56.0 Drug phototoxic responseL56.1 Drug photoallergic responseL56.2 Photocontact dermatitis [berloque dermatitis]L56.3 Solar urticariaL56.4 Polymorphous light eruptionL56.8 Other specified acute skin changes due to ultraviolet radiationL57.1 Actinic reticuloidL57.5 Actinic granulomaL57.8 Other skin changes due to chronic exposure to nonionizing radiationL58.0 Acute radiodermatitisL58.1 Chronic radiodermatitisL59.0 Erythema ab igne [dermatitis ab igne]L59.8 Other specified disorders of the skin and subcutaneous tissue related to radiationL92.0 Granuloma annulareL92.2 Granuloma faciale [eosinophilic granuloma of skin]L95.1 Erythema elevatum diutinumL98.2 Febrile neutrophilic dermatosis [Sweet]


J44.1 Chronic obstructive pulmonary disease with (acute) exacerbationJ45.20 Mild intermittent asthma, uncomplicatedJ45.21 Mild intermittent asthma with (acute) exacerbationJ45.22 Mild intermittent asthma with status asthmaticusJ45.30 Mild persistent asthma, uncomplicatedJ45.31 Mild persistent asthma with (acute) exacerbationJ45.32 Mild persistent asthma with status asthmaticusJ45.40 Moderate persistent asthma, uncomplicatedJ45.41 Moderate persistent asthma with (acute) exacerbationJ45.42 Moderate persistent asthma with status asthmaticusJ45.50 Severe persistent asthma, uncomplicatedJ45.51 Severe persistent asthma with (acute) exacerbationJ45.52 Severe persistent asthma with status asthmaticusJ45.901 Unspecified asthma with (acute) exacerbationJ45.902 Unspecified asthma with status asthmaticusJ45.909 Unspecified asthma, uncomplicatedJ45.990 Exercise induced bronchospasmJ45.991 Cough variant asthmaJ45.998 Other asthmaR05 Cough

Group 4 Paragraph: The following list of ICD-10-CM Codes will be covered for CPT Codes 95070, 95071, 95076,and 95079:

Group 4 Codes:



R06.02 Shortness of breathR06.2 WheezingT36.0X5A Adverse effect of penicillins, initial encounterT36.0X5S Adverse effect of penicillins, sequelaT36.1X5A Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounterT36.1X5S Adverse effect of cephalosporins and other beta-lactam antibiotics, sequelaT36.2X5A Adverse effect of chloramphenicol group, initial encounterT36.2X5S Adverse effect of chloramphenicol group, sequelaT36.3X5A Adverse effect of macrolides, initial encounterT36.3X5S Adverse effect of macrolides, sequelaT36.4X5A Adverse effect of tetracyclines, initial encounterT36.4X5S Adverse effect of tetracyclines, sequelaT36.5X5A Adverse effect of aminoglycosides, initial encounterT36.5X5S Adverse effect of aminoglycosides, sequelaT36.6X5A Adverse effect of rifampicins, initial encounterT36.6X5S Adverse effect of rifampicins, sequelaT36.7X5A Adverse effect of antifungal antibiotics, systemically used, initial encounterT36.7X5S Adverse effect of antifungal antibiotics, systemically used, sequelaT36.8X5A Adverse effect of other systemic antibiotics, initial encounterT36.8X5S Adverse effect of other systemic antibiotics, sequelaT37.0X5A Adverse effect of sulfonamides, initial encounterT37.0X5S Adverse effect of sulfonamides, sequelaT37.1X5A Adverse effect of antimycobacterial drugs, initial encounterT37.1X5S Adverse effect of antimycobacterial drugs, sequelaT37.2X5A Adverse effect of antimalarials and drugs acting on other blood protozoa, initial encounterT37.2X5S Adverse effect of antimalarials and drugs acting on other blood protozoa, sequelaT37.3X5A Adverse effect of other antiprotozoal drugs, initial encounterT37.3X5S Adverse effect of other antiprotozoal drugs, sequelaT37.4X5A Adverse effect of anthelminthics, initial encounterT37.4X5S Adverse effect of anthelminthics, sequelaT37.5X5A Adverse effect of antiviral drugs, initial encounterT37.5X5S Adverse effect of antiviral drugs, sequelaT38.0X5A Adverse effect of glucocorticoids and synthetic analogues, initial encounterT38.0X5S Adverse effect of glucocorticoids and synthetic analogues, sequelaT38.1X5A Adverse effect of thyroid hormones and substitutes, initial encounterT38.1X5S Adverse effect of thyroid hormones and substitutes, sequelaT38.2X5A Adverse effect of antithyroid drugs, initial encounterT38.2X5S Adverse effect of antithyroid drugs, sequelaT38.3X5A Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounterT38.3X5S Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, sequelaT38.4X5A Adverse effect of oral contraceptives, initial encounterT38.4X5S Adverse effect of oral contraceptives, sequelaT38.5X5A Adverse effect of other estrogens and progestogens, initial encounterT38.5X5S Adverse effect of other estrogens and progestogens, sequela



T38.7X5A Adverse effect of androgens and anabolic congeners, initial encounterT38.7X5S Adverse effect of androgens and anabolic congeners, sequelaT38.815A Adverse effect of anterior pituitary [adenohypophyseal] hormones, initial encounterT38.815S Adverse effect of anterior pituitary [adenohypophyseal] hormones, sequelaT38.895A Adverse effect of other hormones and synthetic substitutes, initial encounterT38.895S Adverse effect of other hormones and synthetic substitutes, sequelaT38.995A Adverse effect of other hormone antagonists, initial encounterT38.995S Adverse effect of other hormone antagonists, sequelaT39.015A Adverse effect of aspirin, initial encounterT39.015S Adverse effect of aspirin, sequelaPrinted on 3/2/2016. of 27


T39.095A Adverse effect of salicylates, initial encounterT39.095S Adverse effect of salicylates, sequelaT39.1X5A Adverse effect of 4-Aminophenol derivatives, initial encounterT39.1X5S Adverse effect of 4-Aminophenol derivatives, sequelaT39.2X5A Adverse effect of pyrazolone derivatives, initial encounterT39.2X5S Adverse effect of pyrazolone derivatives, sequelaT39.315A Adverse effect of propionic acid derivatives, initial encounterT39.315S Adverse effect of propionic acid derivatives, sequelaT39.395A Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounterT39.395S Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], sequelaT39.4X5A Adverse effect of antirheumatics, not elsewhere classified, initial encounterT39.4X5S Adverse effect of antirheumatics, not elsewhere classified, sequela


T39.8X5S Adverse effect of other nonopioid analgesics and antipyretics, not elsewhere classified, sequelaT40.0X5A Adverse effect of opium, initial encounterT40.0X5S Adverse effect of opium, sequelaT40.2X5A Adverse effect of other opioids, initial encounterT40.2X5S Adverse effect of other opioids, sequelaT40.3X5A Adverse effect of methadone, initial encounterT40.3X5S Adverse effect of methadone, sequelaT40.4X5A Adverse effect of other synthetic narcotics, initial encounterT40.4X5S Adverse effect of other synthetic narcotics, sequelaT40.5X5A Adverse effect of cocaine, initial encounterT40.5X5S Adverse effect of cocaine, sequelaT40.695A Adverse effect of other narcotics, initial encounterT40.695S Adverse effect of other narcotics, sequelaT40.7X5A Adverse effect of cannabis (derivatives), initial encounterT40.7X5S Adverse effect of cannabis (derivatives), sequelaT40.995A Adverse effect of other psychodysleptics [hallucinogens], initial encounterT40.995S Adverse effect of other psychodysleptics [hallucinogens], sequelaT41.0X5A Adverse effect of inhaled anesthetics, initial encounterT41.0X5S Adverse effect of inhaled anesthetics, sequelaT41.1X5A Adverse effect of intravenous anesthetics, initial encounterT41.1X5S Adverse effect of intravenous anesthetics, sequelaT41.295A Adverse effect of other general anesthetics, initial encounterT41.295S Adverse effect of other general anesthetics, sequelaT41.3X5A Adverse effect of local anesthetics, initial encounterT41.3X5S Adverse effect of local anesthetics, sequelaT41.5X5A Adverse effect of therapeutic gases, initial encounterT41.5X5S Adverse effect of therapeutic gases, sequelaT42.0X5A Adverse effect of hydantoin derivatives, initial encounterT42.0X5S Adverse effect of hydantoin derivatives, sequelaT42.1X5A Adverse effect of iminostilbenes, initial encounterT42.1X5S Adverse effect of iminostilbenes, sequelaT42.2X5A Adverse effect of succinimides and oxazolidinediones, initial encounterT42.2X5S Adverse effect of succinimides and oxazolidinediones, sequelaT42.3X5A Adverse effect of barbiturates, initial encounterT42.3X5S Adverse effect of barbiturates, sequelaT42.4X5A Adverse effect of benzodiazepines, initial encounterT42.4X5S Adverse effect of benzodiazepines, sequelaT42.5X5A Adverse effect of mixed antiepileptics, initial encounterT42.5X5S Adverse effect of mixed antiepileptics, sequelaT42.6X5A Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounterT42.6X5S Adverse effect of other antiepileptic and sedative-hypnotic drugs, sequela


T42.8X5S Adverse effect of antiparkinsonism drugs and other central muscle-tone depressants, sequelaPrinted on 3/2/2016. of 27


T43.015A Adverse effect of tricyclic antidepressants, initial encounterT43.015S Adverse effect of tricyclic antidepressants, sequelaT43.025A Adverse effect of tetracyclic antidepressants, initial encounterT43.025S Adverse effect of tetracyclic antidepressants, sequelaT43.1X5A Adverse effect of monoamine-oxidase-inhibitor antidepressants, initial encounterT43.1X5S Adverse effect of monoamine-oxidase-inhibitor antidepressants, sequelaT43.215A Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounterT43.215S Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, sequelaT43.225A Adverse effect of selective serotonin reuptake inhibitors, initial encounterT43.225S Adverse effect of selective serotonin reuptake inhibitors, sequelaT43.295A Adverse effect of other antidepressants, initial encounterT43.295S Adverse effect of other antidepressants, sequelaT43.3X5A Adverse effect of phenothiazine antipsychotics and neuroleptics, initial encounterT43.3X5S Adverse effect of phenothiazine antipsychotics and neuroleptics, sequelaT43.4X5A Adverse effect of butyrophenone and thiothixene neuroleptics, initial encounterT43.4X5S Adverse effect of butyrophenone and thiothixene neuroleptics, sequelaT43.595A Adverse effect of other antipsychotics and neuroleptics, initial encounterT43.595S Adverse effect of other antipsychotics and neuroleptics, sequelaT43.615A Adverse effect of caffeine, initial encounterT43.615S Adverse effect of caffeine, sequelaT43.625A Adverse effect of amphetamines, initial encounterT43.625S Adverse effect of amphetamines, sequelaT43.635A Adverse effect of methylphenidate, initial encounterT43.635S Adverse effect of methylphenidate, sequelaT43.695A Adverse effect of other psychostimulants, initial encounterT43.695S Adverse effect of other psychostimulants, sequelaT43.8X5A Adverse effect of other psychotropic drugs, initial encounterT43.8X5S Adverse effect of other psychotropic drugs, sequelaT44.0X5A Adverse effect of anticholinesterase agents, initial encounterT44.0X5S Adverse effect of anticholinesterase agents, sequelaT44.1X5A Adverse effect of other parasympathomimetics [cholinergics], initial encounterT44.1X5S Adverse effect of other parasympathomimetics [cholinergics], sequelaT44.2X5A Adverse effect of ganglionic blocking drugs, initial encounterT44.2X5S Adverse effect of ganglionic blocking drugs, sequela



T44.4X5A Adverse effect of predominantly alpha-adrenoreceptor agonists, initial encounterT44.4X5S Adverse effect of predominantly alpha-adrenoreceptor agonists, sequelaT44.5X5A Adverse effect of predominantly beta-adrenoreceptor agonists, initial encounterT44.5X5S Adverse effect of predominantly beta-adrenoreceptor agonists, sequelaT44.6X5A Adverse effect of alpha-adrenoreceptor antagonists, initial encounterT44.6X5S Adverse effect of alpha-adrenoreceptor antagonists, sequelaT44.7X5A Adverse effect of beta-adrenoreceptor antagonists, initial encounterT44.7X5S Adverse effect of beta-adrenoreceptor antagonists, sequelaT44.8X5A Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, initial encounterT44.8X5S Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, sequelaT44.995A Adverse effect of other drug primarily affecting the autonomic nervous system, initial encounterT44.995S Adverse effect of other drug primarily affecting the autonomic nervous system, sequelaT45.0X5A Adverse effect of antiallergic and antiemetic drugs, initial encounterT45.0X5S Adverse effect of antiallergic and antiemetic drugs, sequelaT45.1X5A Adverse effect of antineoplastic and immunosuppressive drugs, initial encounterT45.1X5S Adverse effect of antineoplastic and immunosuppressive drugs, sequelaT45.2X5A Adverse effect of vitamins, initial encounterT45.2X5S Adverse effect of vitamins, sequelaT45.3X5A Adverse effect of enzymes, initial encounterT45.3X5S Adverse effect of enzymes, sequelaPrinted on 3/2/2016. of 27


T45.4X5A Adverse effect of iron and its compounds, initial encounterT45.4X5S Adverse effect of iron and its compounds, sequelaT45.515A Adverse effect of anticoagulants, initial encounterT45.515S Adverse effect of anticoagulants, sequelaT45.525A Adverse effect of antithrombotic drugs, initial encounterT45.525S Adverse effect of antithrombotic drugs, sequelaT45.615A Adverse effect of thrombolytic drugs, initial encounterT45.615S Adverse effect of thrombolytic drugs, sequelaT45.625A Adverse effect of hemostatic drug, initial encounterT45.625S Adverse effect of hemostatic drug, sequelaT45.695A Adverse effect of other fibrinolysis-affecting drugs, initial encounterT45.695S Adverse effect of other fibrinolysis-affecting drugs, sequelaT45.7X5A Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, initial encounterT45.7X5S Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, sequelaT45.8X5A Adverse effect of other primarily systemic and hematological agents, initial encounterT45.8X5S Adverse effect of other primarily systemic and hematological agents, sequelaT46.0X5A Adverse effect of cardiac-stimulant glycosides and drugs of similar action, initial encounterT46.0X5S Adverse effect of cardiac-stimulant glycosides and drugs of similar action, sequelaT46.1X5A Adverse effect of calcium-channel blockers, initial encounterT46.1X5S Adverse effect of calcium-channel blockers, sequelaT46.2X5A Adverse effect of other antidysrhythmic drugs, initial encounterT46.2X5S Adverse effect of other antidysrhythmic drugs, sequelaT46.3X5A Adverse effect of coronary vasodilators, initial encounterT46.3X5S Adverse effect of coronary vasodilators, sequelaT46.4X5A Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounterT46.4X5S Adverse effect of angiotensin-converting-enzyme inhibitors, sequelaT46.5X5A Adverse effect of other antihypertensive drugs, initial encounterT46.5X5S Adverse effect of other antihypertensive drugs, sequelaT46.6X5A Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, initial encounterT46.6X5S Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, sequelaT46.7X5A Adverse effect of peripheral vasodilators, initial encounterT46.7X5S Adverse effect of peripheral vasodilators, sequelaT46.8X5A Adverse effect of antivaricose drugs, including sclerosing agents, initial encounterT46.8X5S Adverse effect of antivaricose drugs, including sclerosing agents, sequelaT46.995A Adverse effect of other agents primarily affecting the cardiovascular system, initial encounterT46.995S Adverse effect of other agents primarily affecting the cardiovascular system, sequelaT47.0X5A Adverse effect of histamine H2-receptor blockers, initial encounterT47.0X5S Adverse effect of histamine H2-receptor blockers, sequelaT47.1X5A Adverse effect of other antacids and anti-gastric-secretion drugs, initial encounterT47.1X5S Adverse effect of other antacids and anti-gastric-secretion drugs, sequelaT47.2X5A Adverse effect of stimulant laxatives, initial encounterT47.2X5S Adverse effect of stimulant laxatives, sequelaT47.3X5A Adverse effect of saline and osmotic laxatives, initial encounterT47.3X5S Adverse effect of saline and osmotic laxatives, sequelaT47.4X5A Adverse effect of other laxatives, initial encounterT47.4X5S Adverse effect of other laxatives, sequelaT47.5X5A Adverse effect of digestants, initial encounterT47.5X5S Adverse effect of digestants, sequelaT47.6X5A Adverse effect of antidiarrheal drugs, initial encounterT47.6X5S Adverse effect of antidiarrheal drugs, sequelaT47.7X5A Adverse effect of emetics, initial encounterT47.7X5S Adverse effect of emetics, sequelaT47.8X5A Adverse effect of other agents primarily affecting gastrointestinal system, initial encounterT47.8X5S Adverse effect of other agents primarily affecting gastrointestinal system, sequelaT48.0X5A Adverse effect of oxytocic drugs, initial encounterT48.0X5S Adverse effect of oxytocic drugs, sequelaT48.1X5A Adverse effect of skeletal muscle relaxants [neuromuscular blocking agents], initial encounterT48.1X5S Adverse effect of skeletal muscle relaxants [neuromuscular blocking agents], sequelaPrinted on 3/2/2016. of 27


T48.295A Adverse effect of other drugs acting on muscles, initial encounterT48.295S Adverse effect of other drugs acting on muscles, sequelaT48.3X5A Adverse effect of antitussives, initial encounterT48.3X5S Adverse effect of antitussives, sequelaT48.4X5A Adverse effect of expectorants, initial encounterT48.4X5S Adverse effect of expectorants, sequelaT48.5X5A Adverse effect of other anti-common-cold drugs, initial encounterT48.5X5S Adverse effect of other anti-common-cold drugs, sequelaT48.6X5A Adverse effect of antiasthmatics, initial encounterT48.6X5S Adverse effect of antiasthmatics, sequelaT48.995A Adverse effect of other agents primarily acting on the respiratory system, initial encounterT48.995S Adverse effect of other agents primarily acting on the respiratory system, sequelaT49.0X5A Adverse effect of local antifungal, anti-infective and anti-inflammatory drugs, initial encounterT49.0X5S Adverse effect of local antifungal, anti-infective and anti-inflammatory drugs, sequelaT49.1X5A Adverse effect of antipruritics, initial encounterT49.1X5S Adverse effect of antipruritics, sequelaT49.2X5A Adverse effect of local astringents and local detergents, initial encounterT49.2X5S Adverse effect of local astringents and local detergents, sequelaT49.3X5A Adverse effect of emollients, demulcents and protectants, initial encounterT49.3X5S Adverse effect of emollients, demulcents and protectants, sequela



T49.5X5A Adverse effect of ophthalmological drugs and preparations, initial encounterT49.5X5S Adverse effect of ophthalmological drugs and preparations, sequelaT49.6X5A Adverse effect of otorhinolaryngological drugs and preparations, initial encounterT49.6X5S Adverse effect of otorhinolaryngological drugs and preparations, sequelaT49.7X5A Adverse effect of dental drugs, topically applied, initial encounterT49.7X5S Adverse effect of dental drugs, topically applied, sequelaT49.8X5A Adverse effect of other topical agents, initial encounterT49.8X5S Adverse effect of other topical agents, sequelaT50.0X5A Adverse effect of mineralocorticoids and their antagonists, initial encounterT50.0X5S Adverse effect of mineralocorticoids and their antagonists, sequelaT50.1X5A Adverse effect of loop [high-ceiling] diuretics, initial encounterT50.1X5S Adverse effect of loop [high-ceiling] diuretics, sequela




T50.A15S Adverse effect of pertussis vaccine, including combinations with a pertussis component, sequelaT50.A25A Adverse effect of mixed bacterial vaccines without a pertussis component, initial encounterT50.A25S Adverse effect of mixed bacterial vaccines without a pertussis component, sequelaT50.A95A Adverse effect of other bacterial vaccines, initial encounterT50.A95S Adverse effect of other bacterial vaccines, sequela



T50.B15A Adverse effect of smallpox vaccines, initial encounterT50.B15S Adverse effect of smallpox vaccines, sequelaT50.B95A Adverse effect of other viral vaccines, initial encounterT50.B95S Adverse effect of other viral vaccines, sequelaT50.Z15A Adverse effect of immunoglobulin, initial encounterT50.Z15S Adverse effect of immunoglobulin, sequelaT50.Z95A Adverse effect of other vaccines and biological substances, initial encounterT50.Z95S Adverse effect of other vaccines and biological substances, sequelaT50.995A Adverse effect of other drugs, medicaments and biological substances, initial encounterT50.995S Adverse effect of other drugs, medicaments and biological substances, sequelaT78.3XXA Angioneurotic edema, initial encounterT78.3XXS Angioneurotic edema, sequelaT78.41XA Arthus phenomenon, initial encounterT78.41XS Arthus phenomenon, sequelaT78.49XA Other allergy, initial encounterT78.49XS Other allergy, sequelaT88.2XXA Shock due to anesthesia, initial encounterT88.2XXS Shock due to anesthesia, sequelaT88.59XA Other complications of anesthesia, initial encounterT88.59XS Other complications of anesthesia, sequela

T88.6XXA Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered,initial encounter

T88.6XXS Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered,sequela

ICD-10 Codes that DO NOT Support Medical NecessityGroup 1 Paragraph: All ICD-10-CM Codes not listed under the ICD-10-CM Codes That Support MedicalNecessity section of this policy will be denied.

Group 1 Codes: N/A

ICD-10 Additional Information

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General InformationAssociated InformationDocumentation RequirementsIt is expected that supportive documentation evidencing the condition and treatment will be documented in themedical record and be available to the Contractor upon request.

Documentation, such as ICD-10-CM codes, supporting the medical necessity of the service must be submittedwith each claim. Claims submitted without such evidence will be denied as not medically reasonable andnecessary.

Utilization GuidelinesThe evaluation of an inhalant may require up to 90 prick-puncture tests followed by up to 40 intracutaneous testswhich are usually performed when prick/puncture tests are negative. Sometimes 60 intracutaneous testsperformed via multi test, in lieu of prick puncture, may be appropriate for selected patients (for example youngchildren, older adults and needle phobic individuals.)

The number of percutaneous tests performed for the evaluation of food sensitivity may require up to 40 tests.

The total number of tests, i.e. prick or intracutaneous, should not exceed generally accepted standards of testingset forth by professional associations. Exceeding these parameters may be justified if preliminary testing failedPrinted on 3/2/2016. of 27

RevisionHistory Date

RevisionHistoryNumber

Revision History Explanation Reason(s) for Change

10/01/2015 R2

The LCD is revised under "General Information" to correctthe bullet format for "Percutaneous Testing", removed"2005 Current Procedural Terminology (CPT), copyright2004 American Medical Assocation" and added the link tothe NCD Food Allergy Testing and Treatment.

• TypographicalError

• Other (Added theNCD link to FoodAllergy Testingand Treatment.)

10/01/2015 R1 Approved FU annual update.• Revisions Due To

ICD-10-CM CodeChanges

• Food Allergy Testing

and immunotherapy failed to control symptoms.

In California, for CPT code 95004, among patients treated by Allergists, over half required fewer than 100 tests.The great majority required less than 120-130 tests, and only 5% required more than 200 tests. Some of thehigh-test group includes repeat testing necessitated by unsatisfactory response to clinical treatment and a clinicalneed for further investigation. For CPT code 95024, among patients treated by Allergists, over half required only12 tests, and only 5% required 70 or more tests. High-utilization testing may be selected for medical reviewwhen inconsistent with clinical practice norms.

Sources of Information and Basis for Decision2005 ICD-9-CM, copyright 2004, Ingenix, Inc.

Contractor Medical Consultants

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Revision History InformationPlease note: Most Revision History entries effective on or before 01/24/2013 display with a Revision HistoryNumber of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as aseparate and distinct row.

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Associated DocumentsAttachments N/A

Related Local Coverage Documents N/A

Related National Coverage Documents NCD(s) 110.11 - Food Allergy Testing and Treatment

Public Version(s) Updated on 09/09/2015 with effective dates 10/01/2015 - N/A Updated on 07/08/2014 witheffective dates 10/01/2015 - N/A Updated on 03/31/2014 with effective dates 10/01/2015 - N/A Back to Top

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