SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: RAST Type Tests

A57043

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57043
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: RAST Type Tests
Article Type
Billing and Coding
Original Effective Date
09/12/2019
Revision Effective Date
08/03/2023
Revision Ending Date
11/15/2023
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act (SSA):

Section 1862 (a)(1)(A)allows coverage and payment for only those services considered medically reasonable and necessary.

Section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34063-RAST Type Tests.

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.

For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)

CPT code 86003 will be covered only thirty (30) times in a year. Services exceeding this parameter will be considered not medically necessary.

CPT codes 86001 and 86005 are not covered services.

Other Comments:

For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their claims.

Limitation of liability and refund requirements apply when denials are anticipated, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
014x Hospital - Laboratory Services Provided to Non-patients
071x Clinic - Rural Health
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
0300 Laboratory - General Classification
0302 Laboratory - Immunology
0309 Laboratory - Other Laboratory
0971 Professional Fees - Laboratory
N/A

CPT/HCPCS Codes

Group 1

(3 Codes)
Group 1 Paragraph

CPT codes 86001 and 86005 are not covered services.

Group 1 Codes
Code Description
86001 ALLERGEN SPECIFIC IGG QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN
86003 ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, CRUDE ALLERGEN EXTRACT, EACH
86005 ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN (EG, DISK, SPONGE, CARD)
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(355 Codes)
Group 1 Paragraph

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

 

The following ICD-10 Codes apply only to CPT code 86003:

Group 1 Codes
Code Description
J30.0 - J30.2 Vasomotor rhinitis - 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 - J45.22 Mild intermittent asthma, uncomplicated - Mild intermittent asthma with status asthmaticus
J45.30 - J45.32 Mild persistent asthma, uncomplicated - Mild persistent asthma with status asthmaticus
J45.40 - J45.42 Moderate persistent asthma, uncomplicated - Moderate persistent asthma with status asthmaticus
J45.50 - J45.52 Severe persistent asthma, uncomplicated - 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
J45.991 Cough variant asthma
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
L50.0 Allergic urticaria
L50.6 Contact urticaria
L50.8 Other urticaria
R06.2 Wheezing
T36.0X5A Adverse effect of penicillins, initial encounter
T36.1X5A Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter
T36.2X5A Adverse effect of chloramphenicol group, initial encounter
T36.3X5A Adverse effect of macrolides, initial encounter
T36.4X5A Adverse effect of tetracyclines, initial encounter
T36.5X5A Adverse effect of aminoglycosides, initial encounter
T36.6X5A Adverse effect of rifampicins, initial encounter
T36.7X5A Adverse effect of antifungal antibiotics, systemically used, initial encounter
T36.8X5A Adverse effect of other systemic antibiotics, initial encounter
T37.0X5A Adverse effect of sulfonamides, initial encounter
T37.1X5A Adverse effect of antimycobacterial drugs, initial encounter
T37.2X5A Adverse effect of antimalarials and drugs acting on other blood protozoa, initial encounter
T37.3X5A Adverse effect of other antiprotozoal drugs, initial encounter
T37.4X5A Adverse effect of anthelminthics, initial encounter
T37.5X5A Adverse effect of antiviral drugs, initial encounter
T37.8X5A Adverse effect of other specified systemic anti-infectives and antiparasitics, initial encounter
T38.0X5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter
T38.1X5A Adverse effect of thyroid hormones and substitutes, initial encounter
T38.2X5A Adverse effect of antithyroid drugs, initial encounter
T38.4X5A Adverse effect of oral contraceptives, initial encounter
T38.5X5A Adverse effect of other estrogens and progestogens, initial encounter
T38.6X5A Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, initial encounter
T38.7X5A Adverse effect of androgens and anabolic congeners, initial encounter
T38.815A Adverse effect of anterior pituitary [adenohypophyseal] hormones, initial encounter
T38.895A Adverse effect of other hormones and synthetic substitutes, initial encounter
T38.995A Adverse effect of other hormone antagonists, initial encounter
T39.015A Adverse effect of aspirin, initial encounter
T39.095A Adverse effect of salicylates, initial encounter
T39.1X5A Adverse effect of 4-Aminophenol derivatives, initial encounter
T39.2X5A Adverse effect of pyrazolone derivatives, initial encounter
T39.315A Adverse effect of propionic acid derivatives, initial encounter
T39.395A Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounter
T39.4X5A Adverse effect of antirheumatics, not elsewhere classified, initial encounter
T39.8X5A Adverse effect of other nonopioid analgesics and antipyretics, not elsewhere classified, initial encounter
T40.0X5A Adverse effect of opium, initial encounter
T40.2X5A Adverse effect of other opioids, initial encounter
T40.3X5A Adverse effect of methadone, initial encounter
T40.495A Adverse effect of other synthetic narcotics, initial encounter
T40.5X5A Adverse effect of cocaine, initial encounter
T40.695A Adverse effect of other narcotics, initial encounter
T40.715A Adverse effect of cannabis, initial encounter
T40.725A Adverse effect of synthetic cannabinoids, initial encounter
T40.995A Adverse effect of other psychodysleptics [hallucinogens], initial encounter
T41.0X5A Adverse effect of inhaled anesthetics, initial encounter
T41.1X5A Adverse effect of intravenous anesthetics, initial encounter
T41.295A Adverse effect of other general anesthetics, initial encounter
T41.3X5A Adverse effect of local anesthetics, initial encounter
T41.5X5A Adverse effect of therapeutic gases, initial encounter
T42.0X5A Adverse effect of hydantoin derivatives, initial encounter
T42.1X5A Adverse effect of iminostilbenes, initial encounter
T42.2X5A Adverse effect of succinimides and oxazolidinediones, initial encounter
T42.3X5A Adverse effect of barbiturates, initial encounter
T42.4X5A Adverse effect of benzodiazepines, initial encounter
T42.5X5A Adverse effect of mixed antiepileptics, initial encounter
T42.6X5A Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounter
T42.8X5A Adverse effect of antiparkinsonism drugs and other central muscle-tone depressants, initial encounter
T43.015A Adverse effect of tricyclic antidepressants, initial encounter
T43.025A Adverse effect of tetracyclic antidepressants, initial encounter
T43.1X5A Adverse effect of monoamine-oxidase-inhibitor antidepressants, initial encounter
T43.215A Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounter
T43.225A Adverse effect of selective serotonin reuptake inhibitors, initial encounter
T43.295A Adverse effect of other antidepressants, initial encounter
T43.3X5A Adverse effect of phenothiazine antipsychotics and neuroleptics, initial encounter
T43.4X5A Adverse effect of butyrophenone and thiothixene neuroleptics, initial encounter
T43.595A Adverse effect of other antipsychotics and neuroleptics, initial encounter
T43.615A Adverse effect of caffeine, initial encounter
T43.625A Adverse effect of amphetamines, initial encounter
T43.635A Adverse effect of methylphenidate, initial encounter
T43.651A Poisoning by methamphetamines accidental (unintentional), initial encounter
T43.651D Poisoning by methamphetamines accidental (unintentional), subsequent encounter
T43.651S Poisoning by methamphetamines accidental (unintentional), sequela
T43.652A Poisoning by methamphetamines intentional self-harm, initial encounter
T43.652D Poisoning by methamphetamines intentional self-harm, subsequent encounter
T43.652S Poisoning by methamphetamines intentional self-harm, sequela
T43.653A Poisoning by methamphetamines, assault, initial encounter
T43.653D Poisoning by methamphetamines, assault, subsequent encounter
T43.653S Poisoning by methamphetamines, assault, sequela
T43.654A Poisoning by methamphetamines, undetermined, initial encounter
T43.654D Poisoning by methamphetamines, undetermined, subsequent encounter
T43.654S Poisoning by methamphetamines, undetermined, sequela
T43.655A Adverse effect of methamphetamines, initial encounter
T43.655D Adverse effect of methamphetamines, subsequent encounter
T43.655S Adverse effect of methamphetamines, sequela
T43.656A Underdosing of methamphetamines, initial encounter
T43.656D Underdosing of methamphetamines, subsequent encounter
T43.656S Underdosing of methamphetamines, sequela
T43.695A Adverse effect of other psychostimulants, initial encounter
T43.8X5A Adverse effect of other psychotropic drugs, initial encounter
T44.0X5A Adverse effect of anticholinesterase agents, initial encounter
T44.1X5A Adverse effect of other parasympathomimetics [cholinergics], initial encounter
T44.2X5A Adverse effect of ganglionic blocking drugs, initial encounter
T44.3X5A Adverse effect of other parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics, initial encounter
T44.4X5A Adverse effect of predominantly alpha-adrenoreceptor agonists, initial encounter
T44.5X5A Adverse effect of predominantly beta-adrenoreceptor agonists, initial encounter
T44.6X5A Adverse effect of alpha-adrenoreceptor antagonists, initial encounter
T44.7X5A Adverse effect of beta-adrenoreceptor antagonists, initial encounter
T44.8X5A Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, initial encounter
T44.995A Adverse effect of other drug primarily affecting the autonomic nervous system, initial encounter
T45.0X5A Adverse effect of antiallergic and antiemetic drugs, initial encounter
T45.1X5A Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter
T45.2X5A Adverse effect of vitamins, initial encounter
T45.3X5A Adverse effect of enzymes, initial encounter
T45.4X5A Adverse effect of iron and its compounds, initial encounter
T45.515A Adverse effect of anticoagulants, initial encounter
T45.525A Adverse effect of antithrombotic drugs, initial encounter
T45.615A Adverse effect of thrombolytic drugs, initial encounter
T45.625A Adverse effect of hemostatic drug, initial encounter
T45.695A Adverse effect of other fibrinolysis-affecting drugs, initial encounter
T45.7X5A Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, initial encounter
T45.8X5A Adverse effect of other primarily systemic and hematological agents, initial encounter
T46.0X5A Adverse effect of cardiac-stimulant glycosides and drugs of similar action, initial encounter
T46.1X5A Adverse effect of calcium-channel blockers, initial encounter
T46.2X5A Adverse effect of other antidysrhythmic drugs, initial encounter
T46.3X5A Adverse effect of coronary vasodilators, initial encounter
T46.4X5A Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounter
T46.5X5A Adverse effect of other antihypertensive drugs, initial encounter
T46.6X5A Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, initial encounter
T46.7X5A Adverse effect of peripheral vasodilators, initial encounter
T46.8X5A Adverse effect of antivaricose drugs, including sclerosing agents, initial encounter
T46.995A Adverse effect of other agents primarily affecting the cardiovascular system, initial encounter
T47.0X5A Adverse effect of histamine H2-receptor blockers, initial encounter
T47.1X5A Adverse effect of other antacids and anti-gastric-secretion drugs, initial encounter
T47.2X5A Adverse effect of stimulant laxatives, initial encounter
T47.3X5A Adverse effect of saline and osmotic laxatives, initial encounter
T47.4X5A Adverse effect of other laxatives, initial encounter
T47.5X5A Adverse effect of digestants, initial encounter
T47.6X5A Adverse effect of antidiarrheal drugs, initial encounter
T47.7X5A Adverse effect of emetics, initial encounter
T47.8X5A Adverse effect of other agents primarily affecting gastrointestinal system, initial encounter
T48.0X5A Adverse effect of oxytocic drugs, initial encounter
T48.1X5A Adverse effect of skeletal muscle relaxants [neuromuscular blocking agents], initial encounter
T48.295A Adverse effect of other drugs acting on muscles, initial encounter
T48.3X5A Adverse effect of antitussives, initial encounter
T48.4X5A Adverse effect of expectorants, initial encounter
T48.5X5A Adverse effect of other anti-common-cold drugs, initial encounter
T48.6X5A Adverse effect of antiasthmatics, initial encounter
T48.995A Adverse effect of other agents primarily acting on the respiratory system, initial encounter
T49.0X5A Adverse effect of local antifungal, anti-infective and anti-inflammatory drugs, initial encounter
T49.1X5A Adverse effect of antipruritics, initial encounter
T49.2X5A Adverse effect of local astringents and local detergents, initial encounter
T49.3X5A Adverse effect of emollients, demulcents and protectants, initial encounter
T49.4X5A Adverse effect of keratolytics, keratoplastics, and other hair treatment drugs and preparations, initial encounter
T49.5X5A Adverse effect of ophthalmological drugs and preparations, initial encounter
T49.6X5A Adverse effect of otorhinolaryngological drugs and preparations, initial encounter
T49.7X5A Adverse effect of dental drugs, topically applied, initial encounter
T49.8X5A Adverse effect of other topical agents, initial encounter
T50.0X5A Adverse effect of mineralocorticoids and their antagonists, initial encounter
T50.1X5A Adverse effect of loop [high-ceiling] diuretics, initial encounter
T50.2X5A Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter
T50.3X5A Adverse effect of electrolytic, caloric and water-balance agents, initial encounter
T50.4X5A Adverse effect of drugs affecting uric acid metabolism, initial encounter
T50.5X5A Adverse effect of appetite depressants, initial encounter
T50.6X5A Adverse effect of antidotes and chelating agents, initial encounter
T50.7X5A Adverse effect of analeptics and opioid receptor antagonists, initial encounter
T50.8X5A Adverse effect of diagnostic agents, initial encounter
T50.A15A Adverse effect of pertussis vaccine, including combinations with a pertussis component, initial encounter
T50.A25A Adverse effect of mixed bacterial vaccines without a pertussis component, initial encounter
T50.A95A Adverse effect of other bacterial vaccines, initial encounter
T50.B15A Adverse effect of smallpox vaccines, initial encounter
T50.B95A Adverse effect of other viral vaccines, initial encounter
T50.Z15A Adverse effect of immunoglobulin, initial encounter
T50.Z95A Adverse effect of other vaccines and biological substances, initial encounter
T50.905A Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter
T50.995A Adverse effect of other drugs, medicaments and biological substances, initial encounter
T63.011A* Toxic effect of rattlesnake venom, accidental (unintentional), initial encounter
T63.012A* Toxic effect of rattlesnake venom, intentional self-harm, initial encounter
T63.013A* Toxic effect of rattlesnake venom, assault, initial encounter
T63.014A* Toxic effect of rattlesnake venom, undetermined, initial encounter
T63.021A* Toxic effect of coral snake venom, accidental (unintentional), initial encounter
T63.022A* Toxic effect of coral snake venom, intentional self-harm, initial encounter
T63.023A* Toxic effect of coral snake venom, assault, initial encounter
T63.024A* Toxic effect of coral snake venom, undetermined, initial encounter
T63.031A* Toxic effect of taipan venom, accidental (unintentional), initial encounter
T63.032A* Toxic effect of taipan venom, intentional self-harm, initial encounter
T63.033A* Toxic effect of taipan venom, assault, initial encounter
T63.034A* Toxic effect of taipan venom, undetermined, initial encounter
T63.041A* Toxic effect of cobra venom, accidental (unintentional), initial encounter
T63.042A* Toxic effect of cobra venom, intentional self-harm, initial encounter
T63.043A* Toxic effect of cobra venom, assault, initial encounter
T63.044A* Toxic effect of cobra venom, undetermined, initial encounter
T63.061A* Toxic effect of venom of other North and South American snake, accidental (unintentional), initial encounter
T63.062A* Toxic effect of venom of other North and South American snake, intentional self-harm, initial encounter
T63.063A* Toxic effect of venom of other North and South American snake, assault, initial encounter
T63.064A* Toxic effect of venom of other North and South American snake, undetermined, initial encounter
T63.071A* Toxic effect of venom of other Australian snake, accidental (unintentional), initial encounter
T63.072A* Toxic effect of venom of other Australian snake, intentional self-harm, initial encounter
T63.073A* Toxic effect of venom of other Australian snake, assault, initial encounter
T63.074A* Toxic effect of venom of other Australian snake, undetermined, initial encounter
T63.081A* Toxic effect of venom of other African and Asian snake, accidental (unintentional), initial encounter
T63.082A* Toxic effect of venom of other African and Asian snake, intentional self-harm, initial encounter
T63.083A* Toxic effect of venom of other African and Asian snake, assault, initial encounter
T63.084A* Toxic effect of venom of other African and Asian snake, undetermined, initial encounter
T63.091A* Toxic effect of venom of other snake, accidental (unintentional), initial encounter
T63.092A* Toxic effect of venom of other snake, intentional self-harm, initial encounter
T63.093A* Toxic effect of venom of other snake, assault, initial encounter
T63.094A* Toxic effect of venom of other snake, undetermined, initial encounter
T63.111A* Toxic effect of venom of gila monster, accidental (unintentional), initial encounter
T63.112A* Toxic effect of venom of gila monster, intentional self-harm, initial encounter
T63.113A* Toxic effect of venom of gila monster, assault, initial encounter
T63.114A* Toxic effect of venom of gila monster, undetermined, initial encounter
T63.121A* Toxic effect of venom of other venomous lizard, accidental (unintentional), initial encounter
T63.122A* Toxic effect of venom of other venomous lizard, intentional self-harm, initial encounter
T63.123A* Toxic effect of venom of other venomous lizard, assault, initial encounter
T63.124A* Toxic effect of venom of other venomous lizard, undetermined, initial encounter
T63.191A* Toxic effect of venom of other reptiles, accidental (unintentional), initial encounter
T63.192A* Toxic effect of venom of other reptiles, intentional self-harm, initial encounter
T63.193A* Toxic effect of venom of other reptiles, assault, initial encounter
T63.194A* Toxic effect of venom of other reptiles, undetermined, initial encounter
T63.2X1A* Toxic effect of venom of scorpion, accidental (unintentional), initial encounter
T63.2X2A Toxic effect of venom of scorpion, intentional self-harm, initial encounter
T63.2X3A* Toxic effect of venom of scorpion, assault, initial encounter
T63.2X4A* Toxic effect of venom of scorpion, undetermined, initial encounter
T63.311A* Toxic effect of venom of black widow spider, accidental (unintentional), initial encounter
T63.312A* Toxic effect of venom of black widow spider, intentional self-harm, initial encounter
T63.313A* Toxic effect of venom of black widow spider, assault, initial encounter
T63.314A* Toxic effect of venom of black widow spider, undetermined, initial encounter
T63.321A* Toxic effect of venom of tarantula, accidental (unintentional), initial encounter
T63.322A* Toxic effect of venom of tarantula, intentional self-harm, initial encounter
T63.323A* Toxic effect of venom of tarantula, assault, initial encounter
T63.324A* Toxic effect of venom of tarantula, undetermined, initial encounter
T63.331A* Toxic effect of venom of brown recluse spider, accidental (unintentional), initial encounter
T63.332A* Toxic effect of venom of brown recluse spider, intentional self-harm, initial encounter
T63.333A* Toxic effect of venom of brown recluse spider, assault, initial encounter
T63.334A* Toxic effect of venom of brown recluse spider, undetermined, initial encounter
T63.391A* Toxic effect of venom of other spider, accidental (unintentional), initial encounter
T63.392A* Toxic effect of venom of other spider, intentional self-harm, initial encounter
T63.393A* Toxic effect of venom of other spider, assault, initial encounter
T63.394A* Toxic effect of venom of other spider, undetermined, initial encounter
T63.411A* Toxic effect of venom of centipedes and venomous millipedes, accidental (unintentional), initial encounter
T63.412A* Toxic effect of venom of centipedes and venomous millipedes, intentional self-harm, initial encounter
T63.413A* Toxic effect of venom of centipedes and venomous millipedes, assault, initial encounter
T63.414A* Toxic effect of venom of centipedes and venomous millipedes, undetermined, initial encounter
T63.421A* Toxic effect of venom of ants, accidental (unintentional), initial encounter
T63.422A* Toxic effect of venom of ants, intentional self-harm, initial encounter
T63.423A* Toxic effect of venom of ants, assault, initial encounter
T63.424A* Toxic effect of venom of ants, undetermined, initial encounter
T63.431A* Toxic effect of venom of caterpillars, accidental (unintentional), initial encounter
T63.432A* Toxic effect of venom of caterpillars, intentional self-harm, initial encounter
T63.433A* Toxic effect of venom of caterpillars, assault, initial encounter
T63.434A* Toxic effect of venom of caterpillars, undetermined, initial encounter
T63.441A* Toxic effect of venom of bees, accidental (unintentional), initial encounter
T63.442A* Toxic effect of venom of bees, intentional self-harm, initial encounter
T63.444A* Toxic effect of venom of bees, undetermined, initial encounter
T63.451A* Toxic effect of venom of hornets, accidental (unintentional), initial encounter
T63.452A* Toxic effect of venom of hornets, intentional self-harm, initial encounter
T63.453A* Toxic effect of venom of hornets, assault, initial encounter
T63.454A* Toxic effect of venom of hornets, undetermined, initial encounter
T63.461A* Toxic effect of venom of wasps, accidental (unintentional), initial encounter
T63.462A* Toxic effect of venom of wasps, intentional self-harm, initial encounter
T63.463A* Toxic effect of venom of wasps, assault, initial encounter
T63.464A* Toxic effect of venom of wasps, undetermined, initial encounter
T63.481A* Toxic effect of venom of other arthropod, accidental (unintentional), initial encounter
T63.482A* Toxic effect of venom of other arthropod, intentional self-harm, initial encounter
T63.483A* Toxic effect of venom of other arthropod, assault, initial encounter
T63.484A* Toxic effect of venom of other arthropod, undetermined, initial encounter
T63.511A* Toxic effect of contact with stingray, accidental (unintentional), initial encounter
T63.512A* Toxic effect of contact with stingray, intentional self-harm, initial encounter
T63.513A* Toxic effect of contact with stingray, assault, initial encounter
T63.514A* Toxic effect of contact with stingray, undetermined, initial encounter
T63.591A* Toxic effect of contact with other venomous fish, accidental (unintentional), initial encounter
T63.592A* Toxic effect of contact with other venomous fish, intentional self-harm, initial encounter
T63.593A* Toxic effect of contact with other venomous fish, assault, initial encounter
T63.594A* Toxic effect of contact with other venomous fish, undetermined, initial encounter
T63.611A* Toxic effect of contact with Portuguese Man-o-war, accidental (unintentional), initial encounter
T63.612A* Toxic effect of contact with Portuguese Man-o-war, intentional self-harm, initial encounter
T63.613A* Toxic effect of contact with Portuguese Man-o-war, assault, initial encounter
T63.614A* Toxic effect of contact with Portuguese Man-o-war, undetermined, initial encounter
T63.621A* Toxic effect of contact with other jellyfish, accidental (unintentional), initial encounter
T63.622A* Toxic effect of contact with other jellyfish, intentional self-harm, initial encounter
T63.623A* Toxic effect of contact with other jellyfish, assault, initial encounter
T63.624A* Toxic effect of contact with other jellyfish, undetermined, initial encounter
T63.631A* Toxic effect of contact with sea anemone, accidental (unintentional), initial encounter
T63.632A* Toxic effect of contact with sea anemone, intentional self-harm, initial encounter
T63.633A* Toxic effect of contact with sea anemone, assault, initial encounter
T63.634A* Toxic effect of contact with sea anemone, undetermined, initial encounter
T63.691A* Toxic effect of contact with other venomous marine animals, accidental (unintentional), initial encounter
T63.692A* Toxic effect of contact with other venomous marine animals, intentional self-harm, initial encounter
T63.693A* Toxic effect of contact with other venomous marine animals, assault, initial encounter
T63.694A* Toxic effect of contact with other venomous marine animals, undetermined, initial encounter
T63.711A* Toxic effect of contact with venomous marine plant, accidental (unintentional), initial encounter
T63.712A* Toxic effect of contact with venomous marine plant, intentional self-harm, initial encounter
T63.713A* Toxic effect of contact with venomous marine plant, assault, initial encounter
T63.714A* Toxic effect of contact with venomous marine plant, undetermined, initial encounter
T63.791A* Toxic effect of contact with other venomous plant, accidental (unintentional), initial encounter
T63.792A* Toxic effect of contact with other venomous plant, intentional self-harm, initial encounter
T63.793A* Toxic effect of contact with other venomous plant, assault, initial encounter
T63.794A* Toxic effect of contact with other venomous plant, undetermined, initial encounter
T63.811A* Toxic effect of contact with venomous frog, accidental (unintentional), initial encounter
T63.812A* Toxic effect of contact with venomous frog, intentional self-harm, initial encounter
T63.813A* Toxic effect of contact with venomous frog, assault, initial encounter
T63.814A* Toxic effect of contact with venomous frog, undetermined, initial encounter
T63.821A* Toxic effect of contact with venomous toad, accidental (unintentional), initial encounter
T63.822A* Toxic effect of contact with venomous toad, intentional self-harm, initial encounter
T63.823A* Toxic effect of contact with venomous toad, assault, initial encounter
T63.824A* Toxic effect of contact with venomous toad, undetermined, initial encounter
T63.831A* Toxic effect of contact with other venomous amphibian, accidental (unintentional), initial encounter
T63.832A* Toxic effect of contact with other venomous amphibian, intentional self-harm, initial encounter
T63.833A* Toxic effect of contact with other venomous amphibian, assault, initial encounter
T63.834A* Toxic effect of contact with other venomous amphibian, undetermined, initial encounter
T63.891A* Toxic effect of contact with other venomous animals, accidental (unintentional), initial encounter
T63.892A* Toxic effect of contact with other venomous animals, intentional self-harm, initial encounter
T63.893A* Toxic effect of contact with other venomous animals, assault, initial encounter
T63.894A* Toxic effect of contact with other venomous animals, undetermined, initial encounter
T78.00XA Anaphylactic reaction due to unspecified food, initial encounter
T78.01XA Anaphylactic reaction due to peanuts, initial encounter
T78.02XA Anaphylactic reaction due to shellfish (crustaceans), initial encounter
T78.03XA Anaphylactic reaction due to other fish, initial encounter
T78.04XA Anaphylactic reaction due to fruits and vegetables, initial encounter
T78.05XA Anaphylactic reaction due to tree nuts and seeds, initial encounter
T78.06XA Anaphylactic reaction due to food additives, initial encounter
T78.07XA Anaphylactic reaction due to milk and dairy products, initial encounter
T78.08XA Anaphylactic reaction due to eggs, initial encounter
T78.09XA Anaphylactic reaction due to other food products, initial encounter
T78.2XXA Anaphylactic shock, unspecified, initial encounter
T78.3XXA Angioneurotic edema, initial encounter
T78.40XA Allergy, unspecified, initial encounter
T78.49XA Other allergy, initial encounter
T88.59XA Other complications of anesthesia, initial encounter
T88.6XXA Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, initial encounter
Z91.014 Allergy to mammalian meats
Z91.048 Other nonmedicinal substance allergy status
Z91.09 Other allergy status, other than to drugs and biological substances
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*ICD-10-CM codes T63.011A-T63.2X4A should be reported for venom hypersensitivity.

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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill 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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
014x Hospital - Laboratory Services Provided to Non-patients
071x Clinic - Rural Health
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital
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Revenue Codes

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

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.


Code Description
0300 Laboratory - General Classification
0302 Laboratory - Immunology
0309 Laboratory - Other Laboratory
0971 Professional Fees - Laboratory
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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
08/03/2023 R10

Revision Effective: 08/03/2023

Revision Explanation: Annual review, no changes.

10/01/2022 R9

Revision Effective: 10/01/2022

Revision Explanation: Annual ICD-10 Update, Added to Group 1 T43.651A, T43.651D, T43.651S, T43.652A, T43.652D, T43.652S, T43.653A, T43.653D, T43.653S, T43.654A, T43.654D, T43.654S, T43.655A, T43.655D, T43.655S, T43.656A, T43.656D, and T43.656S

08/04/2022 R8

Revision Effective: 08/04/2022

Revision Explanation: Annual review, no changes were made.

10/01/2021 R7

Revision Effective: 10/01/2021
Revision Explanation: Annual ICD-10 update. Under ICD-10-CM Codes that Support Medical Necessity Group 1 : Code T40.7X5A was removed and added T40.715A and T40.725A

10/01/2021 R6

Revision Effective: 10/01/2021
Revision Explanation: Annual ICD-10 update. Under ICD-10-CM Codes that Support Medical Necessity Group 1 : Code added Z91.014.

07/29/2021 R5

Revision Effective: 07/29/2021

Revision Explanation: Annual review, no changes were made.

10/01/2020 R4

Revision Effective: 10/01/2020
Revision Explanation: During annual ICD-10 review T40.4X5A was deleted and replaced with T40.495A.

12/05/2019 R3

Revision Effective: n/a

Revision Explanation: Annual review, no changes made.

12/05/2019 R2

Revision Effective: 12/05/2019

Revision Explanation: Added other comments section in text and regulations to CMS National Policy section.

09/26/2019 R1

Revision Effective: 09/26/2019

Revision Explanation: Added additional Billing and Coding from associated information section from policy based on CR 10901.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L34063 - RAST Type Tests
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/10/2023 11/16/2023 - N/A Currently in Effect View
07/25/2023 08/03/2023 - 11/15/2023 Superseded You are here
09/20/2022 10/01/2022 - 08/02/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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