95004 Percut Tests w/ Extrac Immed React # Allergy testing – Percut allergy skin tests – Percutaneous tests (prick or puncture), specify number of tests (1 prick = 1 test) – Average fee amount $6 – $8
86003 Allergen specific ige –
95024 Intracutaneous (intradermal) tests, specify number of tests. Use this code when doing no more than one intradermal test per antigen. (e.g. MQT)
95027 Intracutaneous (intradermal) tests, sequential and incremental, specify number of tests. Use this code when doing more than one ID test per antigen. (e.g. IDT) 95024 and 95027 may be billed at the same time.
Coverage Indications, Limitations, and/or Medical Necessity
Allergy skin testing is a clinical procedure that is used to evaluate an immunologic response to allergenic material. The need for testing and interpretation of test findings must be correlated with signs and symptoms of possible allergies as determined by a complete history and physical examination of the patient. The number and type of antigens used for testing must be chosen judiciously given the patient’s presentation and the tester’s clinical judgment.
- Testing must correlate specifically to the patient’s history and physical findings.
- The test technique and/or allergens tested must have proven efficacy demonstrated through scientifically valid medical studies published in peer-reviewed literature.
- Allergy testing must be performed on patients whose environment provides the reasonable probability of exposure to the specific antigen tested.
Percutaneous, Intradermal, Intracutaneous Testing
- Inhalants.
- Foods.
- Hymenoptera (stinging insects).
- Specific drugs (penicillins and macromolecular agents).
- Inhalants.
- Hymenoptera (stinging insects).
- Specific drugs (penicillins and macromolecular agents).
Patch Testing
A positive patch test provides a very specific etiology of a patient’s allergic contact dermatitis. Avoidance of the identified allergen(s) is the treatment of choice.
This is a covered procedure only when used to diagnose allergic contact dermatitis after the following exposures:
- Due to detergents (692.0).
- Due to oils and greases (692.1).
- Due to solvents (692.2).
- Due to drugs and medicines in contact with skin (692.3).
- Due to other chemical products (692.4).
- Due to food in contact with skin (692.5).
- Due to plants [except food] (692.6).
- Dermatitis due to cosmetics (692.81).
- Dermatitis due to metals (692.83).
- Dermatitis due to other (692.89). ICD-9-CM code 692.89 is used for dermatitis due to: cold weather, furs, hot weather and preservatives).
- Dermatitis due to latex allergy. Use ICD-9-CM code 692.89 for this indication.
- Dermatitis due to unspecified cause (692.9) is to be utilized for those patients with suspected allergic contact dermatitis but in whom the etiology is not apparent. Prior unresponsive treatments (topical medications, etc.) should be documented in the patient’s chart before initiating patch tests.
Limitations
- Provocative and neutralization testing and neutralization therapy of food allergies (sublingual, intracutaneous and subcutaneous) are excluded from Medicare coverage because available evidence does not show these tests and therapies are effective.
- Qualitative multi-allergen screens have insufficient literature demonstrating clear-cut clinical utility and are therefore, non-covered.
- Late reactions occurring with allergenic extracts are of unclear clinical significance and are therefore, non-covered.
- Intradermal testing for food allergens.
- Food allergen testing for patients who present with respiratory symptoms other than wheezing and asthma.
- Food allergen testing for patients who present with gastrointestinal symptoms suggestive of food intolerance.
- Skin endpoint testing.
- Allergy testing for antigens for which no clinical efficacy is documented in peer-reviewed literature. Such antigens include but are not limited to the following:
- Grain mill dust (pollen grains of cereals/related crops are large; they do not become airborne).
- Tobacco smoke (no component has ever been shown to be a respiratory allergen).
- Orris root (almost never used in cosmetics these days; test adds nothing to evaluation).
- Dandelion (non-allergenic; no pollen produced).
- Marigold (non-allergenic; no airborne pollen produced).
- Honeysuckle (non-allergenic; non-significant airborne pollen produced).
Note: See related article for coding guidelines.
- Tobacco leaf for tobacco workers.
- Pyrethrum for florists (non-allergenic; found in some insecticides; cross-reacts strongly with ragweed).
- Goldenrod for florists (pollen not carried by wind).
- Soybean dust for workers in food processing plants.
- Wool for patients exposed to sheep or unprocessed wool (processed wool is non-allergenic).
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Note:
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Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
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95004©
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Percut allergy skin tests
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95010©
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Sensitivity skin tests
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95015©
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Sensitivity skin tests
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95024©
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Id allergy test, drug/bug
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95044©
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Allergy patch tests
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1. IgE Specific Antibody (e.g., RAST, micro-Elisa, immunocap) if clinically indicated for history of severe urticaria, hives, or severe allergy, when skin testing is inappropriate.
2. Skin tests (scratch, intradermal, pricks)
3. Patch application tests
4. Drug Provocation testing
5. Skin Endpoint Titration (SET). Skin endpoint titration is effective for quantifying patient sensitivity and for providing a safe starting dose for immunotherapy. SET has not been shown to be an effective guide to a final therapeutic dose.
Coding Guidelines: Allergy Testing and Immunotherapy.
If percutaneous or intracutaneous (intradermal) single test (CPT codes 95004 or 95024) and “sequential and incremental” tests (CPT codes, 95017, 95018, or 95027) are performed on the same date of service, both the “sequential and incremental” test and single test codes may be reported if the tests are for different allergens or different dilutions of the same allergen. The unit of service to report is the number of separate tests. A single test and a “sequential and incremental” test for the same dilution of an allergen should not be reported separately on the same date of service. For example, if the single test for an antigen is positive and the physician proceeds to “sequential and incremental” tests with three additional different dilutions of the same antigen, the physician may report one unit of service for the single test code and three units of service for the “sequential and incremental” test code.
Photo patch tests (CPT code 95052) consist of applying a patch(s) containing allergenic substance(s) (same antigen/same session) to the skin and exposing the skin to light. Physicians should not unbundle this service by reporting both CPT code 95044 (patch or application tests) plus CPT code 95056 (photo tests) rather than CPT code 95052.
Evaluation and management (E/M) codes reported with allergy testing or allergy immunotherapy are appropriate only if a significant, separately identifiable service is performed. If E/M services are reported, modifier 25 should be utilized.
95004–95079 Allergy testing Bill with a count representing the number of tests performed; 95004, 95024 and 95044 reimbursed for professional services only 95004, 95024, 95027
Percutaneous tests with allergenic extracts, Intracutaneous tests with allergenic extracts immediate type reaction and intracutaneous tests sequential and incremental with allergenic extracts These codes include the test interpretation and
report
ICD-10 Codes that Support Medical Necessity
The following ICD-10-CM codes apply only to CPT code 86003:
H10.10 Acute atopic conjunctivitis, unspecified eye
H10.11 Acute atopic conjunctivitis, right eye
H10.12 Acute atopic conjunctivitis, left eye
H10.13 Acute atopic conjunctivitis, bilateral
H10.411 Chronic giant papillary conjunctivitis, right eye
H10.412 Chronic giant papillary conjunctivitis, left eye
H10.413 Chronic giant papillary conjunctivitis, bilateral
H10.419 Chronic giant papillary conjunctivitis, unspecified eye
H10.45 Other chronic allergic conjunctivitis
J30.0 Vasomotor rhinitis
J30.1 Allergic rhinitis due to pollen
J30.2 Other seasonal allergic rhinitis
J30.5 Allergic rhinitis due to food
J30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander
J30.89 Other allergic rhinitis
J30.9 Allergic rhinitis, unspecified
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
J45.998 Other asthma
L20.0 Besnier’s prurigo
L20.81 Atopic neurodermatitis
L20.82 Flexural eczema
L20.84 Intrinsic (allergic) eczema
L20.89 Other atopic dermatitis
L20.9 Atopic dermatitis, unspecified
L23.9 Allergic contact dermatitis, unspecified cause
L24.9 Irritant contact dermatitis, unspecified cause
L25.9 Unspecified contact dermatitis, unspecified cause
L27.0 Generalized skin eruption due to drugs and medicaments taken internally
L27.1 Localized skin eruption due to drugs and medicaments taken internally
L27.2 Dermatitis due to ingested food
L27.8 Dermatitis due to other substances taken internally
L27.9 Dermatitis due to unspecified substance taken internally
L30.0 Nummular dermatitis
L30.2 Cutaneous autosensitization
L30.8 Other specified dermatitis
L30.9 Dermatitis, unspecified
L50.0 Allergic urticaria
L50.3 Dermatographic urticaria
L50.9 Urticaria, unspecified
R21 Rash and other nonspecific skin eruption
T36.0X5A Adverse effect of penicillins, initial encounter
T36.0X5D Adverse effect of penicillins, subsequent encounter
T36.0X5S Adverse effect of penicillins, sequela
T36.1X5A Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter
T36.1X5D Adverse effect of cephalosporins and other beta-lactam antibiotics, subsequent encounter
T36.1X5S Adverse effect of cephalosporins and other beta-lactam antibiotics, sequela
T36.2X5A Adverse effect of chloramphenicol group, initial encounter
T36.2X5D Adverse effect of chloramphenicol group, subsequent encounter
T36.2X5S Adverse effect of chloramphenicol group, sequela
T36.3X5A Adverse effect of macrolides, initial encounter
T36.3X5D Adverse effect of macrolides, subsequent encounter
T36.3X5S Adverse effect of macrolides, sequela
T36.4X5A Adverse effect of tetracyclines, initial encounter
T36.4X5D Adverse effect of tetracyclines, subsequent encounter
T36.4X5S Adverse effect of tetracyclines, sequela
T36.5X5A Adverse effect of aminoglycosides, initial encounter
T36.5X5D Adverse effect of aminoglycosides, subsequent encounter
T36.5X5S Adverse effect of aminoglycosides, sequela
T36.6X5A Adverse effect of rifampicins, initial encounter
T36.6X5D Adverse effect of rifampicins, subsequent encounter
T36.6X5S Adverse effect of rifampicins, sequela
T36.7X5A Adverse effect of antifungal antibiotics, systemically used, initial encounter
T36.7X5D Adverse effect of antifungal antibiotics, systemically used, subsequent encounter
T36.7X5S Adverse effect of antifungal antibiotics, systemically used, sequela
T36.8X5A Adverse effect of other systemic antibiotics, initial encounter
T36.8X5D Adverse effect of other systemic antibiotics, subsequent encounter
T36.8X5S Adverse effect of other systemic antibiotics, sequela
T36.95XA Adverse effect of unspecified systemic antibiotic, initial encounter
T36.95XD Adverse effect of unspecified systemic antibiotic, subsequent encounter
T36.95XS Adverse effect of unspecified systemic antibiotic, sequela
T37.0X5A Adverse effect of sulfonamides, initial encounter
T37.0X5D Adverse effect of sulfonamides, subsequent encounter
T37.0X5S Adverse effect of sulfonamides, sequela
T37.1X5A Adverse effect of antimycobacterial drugs, initial encounter
T37.1X5D Adverse effect of antimycobacterial drugs, subsequent encounter
T37.1X5S Adverse effect of antimycobacterial drugs, sequela
T37.2X5A Adverse effect of antimalarials and drugs acting on other blood protozoa, initial encounter
T37.2X5D Adverse effect of antimalarials and drugs acting on other blood protozoa, subsequent encounter
T37.2X5S Adverse effect of antimalarials and drugs acting on other blood protozoa, sequela
T37.3X5A Adverse effect of other antiprotozoal drugs, initial encounter
T37.3X5D Adverse effect of other antiprotozoal drugs, subsequent encounter
T37.3X5S Adverse effect of other antiprotozoal drugs, sequela
T37.4X5A Adverse effect of anthelminthics, initial encounter
T37.4X5D Adverse effect of anthelminthics, subsequent encounter
T37.4X5S Adverse effect of anthelminthics, sequela
T37.5X5A Adverse effect of antiviral drugs, initial encounter
T37.5X5D Adverse effect of antiviral drugs, subsequent encounter
T37.5X5S Adverse effect of antiviral drugs, sequela
T37.8X5A Adverse effect of other specified systemic anti-infectives and antiparasitics, initial encounter
T37.8X5D Adverse effect of other specified systemic anti-infectives and antiparasitics, subsequent encounter
T37.8X5S Adverse effect of other specified systemic anti-infectives and antiparasitics, sequela
T37.95XA Adverse effect of unspecified systemic anti-infective and antiparasitic, initial encounter
T37.95XD Adverse effect of unspecified systemic anti-infective and antiparasitic, subsequent encounter
T37.95XS Adverse effect of unspecified systemic anti-infective and antiparasitic, sequela
T38.0X5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter
T38.0X5D Adverse effect of glucocorticoids and synthetic analogues, subsequent encounter
T38.0X5S Adverse effect of glucocorticoids and synthetic analogues, sequela
T38.1X5A Adverse effect of thyroid hormones and substitutes, initial encounter
T38.1X5D Adverse effect of thyroid hormones and substitutes, subsequent encounter
T38.1X5S Adverse effect of thyroid hormones and substitutes, sequela
T38.2X5A Adverse effect of antithyroid drugs, initial encounter
T38.2X5D Adverse effect of antithyroid drugs, subsequent encounter
T38.2X5S Adverse effect of antithyroid drugs, sequela
T38.4X5A Adverse effect of oral contraceptives, initial encounter
T38.4X5D Adverse effect of oral contraceptives, subsequent encounter
T38.4X5S Adverse effect of oral contraceptives, sequela
T38.5X5A Adverse effect of other estrogens and progestogens, initial encounter
T38.5X5D Adverse effect of other estrogens and progestogens, subsequent encounter
T38.5X5S Adverse effect of other estrogens and progestogens, sequela
T38.6X5A Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, initial encounter
T38.6X5D Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, subsequent encounter
T38.6X5S Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, sequela
T38.7X5A Adverse effect of androgens and anabolic congeners, initial encounter
T38.7X5D Adverse effect of androgens and anabolic congeners, subsequent encounter
T38.7X5S Adverse effect of androgens and anabolic congeners, sequela
T38.805A Adverse effect of unspecified hormones and synthetic substitutes, initial encounter
T38.805D Adverse effect of unspecified hormones and synthetic substitutes, subsequent encounter
T38.805S Adverse effect of unspecified hormones and synthetic substitutes, sequela
T38.815A Adverse effect of anterior pituitary [adenohypophyseal] hormones, initial encounter
T38.815D Adverse effect of anterior pituitary [adenohypophyseal] hormones, subsequent encounter
T38.815S Adverse effect of anterior pituitary [adenohypophyseal] hormones, sequela
T38.895A Adverse effect of other hormones and synthetic substitutes, initial encounter
T38.895D Adverse effect of other hormones and synthetic substitutes, subsequent encounter
T38.895S Adverse effect of other hormones and synthetic substitutes, sequela
T38.905A Adverse effect of unspecified hormone antagonists, initial encounter
T38.905D Adverse effect of unspecified hormone antagonists, subsequent encounter
T38.905S Adverse effect of unspecified hormone antagonists, sequela
T38.995A Adverse effect of other hormone antagonists, initial encounter
T38.995D Adverse effect of other hormone antagonists, subsequent encounter
T38.995S Adverse effect of other hormone antagonists, sequela
T39.015A Adverse effect of aspirin, initial encounter
T39.015D Adverse effect of aspirin, subsequent encounter
T39.015S Adverse effect of aspirin, sequela
T39.095A Adverse effect of salicylates, initial encounter
T39.095D Adverse effect of salicylates, subsequent encounter
T39.095S Adverse effect of salicylates, sequela
T39.1X5A Adverse effect of 4-Aminophenol derivatives, initial encounter
T39.1X5D Adverse effect of 4-Aminophenol derivatives, subsequent encounter
T39.1X5S Adverse effect of 4-Aminophenol derivatives, sequela
T39.2X5A Adverse effect of pyrazolone derivatives, initial encounter
T39.2X5D Adverse effect of pyrazolone derivatives, subsequent encounter
T39.2X5S Adverse effect of pyrazolone derivatives, sequela
T39.315A Adverse effect of propionic acid derivatives, initial encounter
ICD-9-CM Codes That Support Medical Necessity
372.05
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Acute atopic conjunctivitis
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372.13–372.14
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Chronic conjunctivitis
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471.0
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Polyp of nasal cavity
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471.8
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Other polyp of sinus
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472.0
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Chronic rhinitis
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473.0–473.3
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Chronic sinusitis
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473.8–473.9
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Chronic sinusitis
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477.0
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Allergic rhinitis due to pollen
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477.2
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Allergic rhinitis, due to animal (cat) (dog) hair and dander
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477.8–477.9
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Allergic rhinitis
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478.0
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Hypertrophy of nasal turbinates
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493.00–493.02
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Extrinsic asthma
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493.20–493.22
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Chronic obstructive asthma
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493.90–493.92
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Asthma, unspecified
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691.8
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Other atopic dermatitis and related conditions
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693.1
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Dermatitis due to food taken internally
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698.9
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Pruritus and related conditions, unspecified pruritic disorder
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708.0–708.1
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Urticaria
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708.8
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Other specified urticaria
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989.5
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Toxic effect of venom
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995.0–995.1
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Certain adverse effects not elsewhere classified
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995.27
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Other drug allergy
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V14.0
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Penicillin, personal history of allergy to medicinal agents
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V14.7
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Serum or vaccine, personal history of allergy to medicinal agents
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V15.01 – V15.07
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Allergy, other than to medicinal agents
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372.05
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Acute atopic conjunctivitis
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372.13–372.14
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Chronic conjunctivitis
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471.0
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Polyp of nasal cavity
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471.8
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Other polyp of sinus
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472.0
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Chronic rhinitis
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473.0–473.3
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Chronic sinusitis
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473.8–473.9
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Chronic sinusitis
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477.0
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Allergic rhinitis
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477.2
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Allergic rhinitis, due to animal (cat) (dog) hair and dander
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477.8–477.9
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Allergic rhinitis due to other allergen
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478.0
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Hypertrophy of nasal turbinates
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493.00–493.02
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Extrinsic asthma
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493.20–493.22
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Chronic obstructive asthma
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493.90–493.92
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Asthma, unspecified
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691.8
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Other atopic dermatitis and related conditions
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698.9
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Pruritus and related conditions, unspecified pruritic disorder
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708.0–708.1
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Urticaria
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708.8
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Other specified urticaria
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989.5
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Toxic effect of venom
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995.0–995.1
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Certain adverse effects not elsewhere classified
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995.27
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Other drug allergy
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V14.0 – V14.3
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Personal history of allergy to medicinal agents
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V14.7
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Personal history of allergy to medicinal agents
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V15.06 – V15.07
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Allergy, other than to medicinal agents
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692.0–692.6
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Contact dermatitis and other eczema
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692.81
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Dermatitis due to cosmetics
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692.83–692.84
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Contact dermatitis and other eczema
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692.89
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Contact dermatitis and other eczema due to other specified agents
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692.9
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Contact dermatitis and other eczema unspecified cause
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- The selection of antigens should be individualized, based on the history and physical examination.
- Medicare expects that all patients will not be tested for the same antigens or receive the same number/type of tests.
- Medicare would not expect that more than 75 percutaneous tests per year are medically necessary for the management of an individual patient. More than 75 tests per year may be allowed upon review when the clinical circumstances documented in the patient’s medical record substantiate the need for additional tests.
- Medicare would not expect that more than 20 intradermal tests per year are medically necessary for the management of an individual patient. More than 20 tests per year may be allowed upon review when the clinical circumstances documented in the patient’s medical record substantiate the need for additional tests.
- Medicare would not expect allergy patch testing to be routinely done on an annual basis. Rather it should be reserved for those patients whose occupational or environmental exposures have caused an allergic contact dermatitis, the cause of which cannot be determined by usual historical or clinical means.
- Medicare would not expect that more than 30 patch tests (a standard series of 24 allergens with controls or individual patch test allergens) per beneficiary per year is medically necessary for the management of an individual patient. The medical necessity of the frequency of patch testing must be documented in the medical record.