Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by “+”:
|
Allergy testing:
|
Epicutaneous (scratch, prick, or puncture):
|
CPT codes covered if selection criteria are met:
|
95004 |
Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests [not covered AFTER allergen immunotherapy] |
95017 |
Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests [not covered AFTER allergen immunotherapy] |
95018 |
Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests [not covered AFTER allergen immunotherapy] |
CPT codes not covered for indications listed in the CPB:
|
0165U |
Peanut allergen-specific IgE and quantitative assessment of 64 epitopes using enzyme-linked immunosorbent assay (ELISA), blood, individual epitope results and interpretation [VeriMAP Peanut Dx] |
0178U |
Peanut allergen-specific quantitative assessment of multiple epitopes using enzyme-linked immunosorbent assay (ELISA), blood, report of minimum eliciting exposure for a clinical reaction |
ICD-10 codes covered if selection criteria are met:
|
J30.1 – J30.9 |
Allergic rhinitis |
L20.84 |
Intrinsic (allergic) eczema |
L25.4 |
Unspecified contact dermatitis due to food in contact with skin |
L27.2 |
Dermatitis due to ingested food |
L50.0 |
Allergic urticaria |
T50.995+ |
Adverse effect of other drugs, medicaments and biological substances |
T63.001+ – T63.94x+ |
Toxic effect of contact with venomous animals and plants |
T78.00+ – T78.09+ |
Anaphylactic shock due to adverse food reaction |
T78.1+ |
Other adverse food reactions, not elsewhere classified |
Intradermal (Intracutaneous) when IgE-mediated reactions occur:
|
CPT codes covered if selection criteria are met:
|
95024 |
Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests |
95027 |
Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report by a physician, specify number of tests |
95028 |
Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify number of tests |
ICD-10 codes covered if selection criteria are met:
|
J30.1 – J30.9 |
Allergic rhinitis |
L20.84 |
Intrinsic (allergic) eczema |
L25.4 |
Unspecified contact dermatitis due to food in contact with skin |
L27.2 |
Dermatitis due to ingested food |
L50.0 |
Allergic urticaria |
T50.995+ |
Adverse effect of other drugs, medicaments and biological substances |
T63.001+ – T63.94x+ |
Toxic effect of contact with venomous animals and plants |
T78.00+ – T78.09+ |
Anaphylactic shock due to adverse food reaction |
T78.1+ |
Other adverse food reactions, not elsewhere classified |
Skin Endpoint Titration (SET):
|
CPT codes covered if selection criteria are met:
|
95027 |
Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report by a physician, specify number of tests |
ICD-10 codes covered if selection criteria are met:
|
J30.1 – J30.9 |
Allergic rhinitis |
T63.001+ – T63.94x+ |
Toxic effect of contact with venomous animals and plants |
Z91.030 – Z91.038 |
Insect allergy status |
Skin Patch Testing:
|
CPT codes covered if selection criteria are met:
|
95044 |
Patch or application tests(s) (specify number of tests) |
ICD-10 codes covered if selection criteria are met:
|
L20.84 |
Intrinsic (allergic) eczema |
L23.0 – L23.9 |
Allergic contact dermatitis |
L50.0 |
Allergic urticaria |
ICD-10 codes not covered for indications listed in the CPB:
|
K52.21 |
Food protein-induced enterocolitis syndrome |
K58.0 – K58.9 |
Irritable bowel syndrome |
Photo Patch Test:
|
CPT codes covered if selection criteria are met:
|
95052 |
Photo patch test(s) (specify number of tests) |
ICD-10 codes covered if selection criteria are met:
|
L56.1 |
Drug photoallergic response |
L56.2 |
Photocontact dermatitis [berloque dermatitis] |
L56.3 |
Solar urticaria |
Photo Tests:
|
CPT codes covered if selection criteria are met:
|
95056 |
Photo tests |
ICD-10 codes covered if selection criteria are met:
|
L56.1 |
Drug photoallergic response |
L56.2 |
Photocontact dermatitis [berloque dermatitis] |
L56.3 |
Solar urticaria |
Bronchial Challenge Test:
|
CPT codes covered if selection criteria are met:
|
95070 |
Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with histamine, methacholine, or similar compounds |
95071 |
with antigens or gases, specify |
Other CPT codes related to the CPB:
|
94150 |
Vital capacity, total (separate procedure) |
94200 |
Maximum breathing capacity, maximum voluntary ventilation |
94621 |
Pulmonary stress testing; complex (including measurements of CO2 production, O2 uptake, and electrocardiographic recordings) |
94680 |
Oxygen uptake, expired gas analysis; rest and exercise, direct, simple |
94681 |
including CO2 output, percentage oxygen extracted |
94690 |
rest, indirect (separate procedure) |
94726 |
Plethysmography for determination of lung volumes and, when performed, airway resistance |
94729 |
Diffusing capacity (eg, carbon monoxide, membrane) (List separately in addition to code for primary procedure) |
94770 |
Carbon dioxide, expired gas determination by infrared analyzer |
HCPCS codes covered if selection criteria are met:
|
J7674 |
Methacholine chloride administered as inhalation solution through a nebulizer, per 1mg |
ICD-10 codes covered if selection criteria are met:
|
J45.20 – J45.998 |
Asthma |
J67.0 – J67.9 |
Hypersensitivity pneumonitis due to organic dust |
J82 |
Pulmonary eosinophilia, not elsewhere classified |
Exercise Challenge Testing:
|
CPT codes covered if selection criteria are met:
|
94010 |
Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation |
94060 |
Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration |
94070 |
Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents (e.g., antigen(s), cold air, methacholine) |
94150 |
Vital capacity, total (separate procedure) |
94200 |
Maximum breathing capacity, maximum voluntary ventilation |
94240 |
Functional residual capacity or residual volume; helium method, nitrogen open circuit method, or other method |
94350 |
Determination of maldistribution of inspired gas; multiple breath nitrogen washout curve including alveolar nitrogen or helium equilibration time |
94360 |
Determination of resistance to airflow, oscillatory or plethysmographic methods |
94375 |
Respiratory flow volume loop |
94617 |
Exercise test for bronchospasm, including pre- and post-spirometry, electrocardiographic recording(s), and pulse oximetry |
94618 |
Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed |
94621 |
Pulmonary stress testing; complex (including measurements of CO2 production, O2uptake, and electrocardiographic recordings) |
94680 |
Oxygen uptake, expired gas analysis; rest and exercise, direct, simple |
94681 |
including CO2 output, percentage oxygen extracted |
94690 |
rest, indirect (separate procedure) |
94720 |
Carbon monoxide diffusing capacity (e.g., single breath, steady state) |
94770 |
Carbon dioxide, expired gas determination by infrared analyzer |
96419 |
Exercise test for bronchospasm, including pre- and post-spirometry and pulse oximetry; without electrocardiographic recording(s) |
HCPCS codes covered if selection criteria are met:
|
J7674 |
Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg |
ICD-10 codes covered if selection criteria are met:
|
J45.990 |
Exercise induced bronchospasm |
Ingestion (Oral) Challenge Test:
|
CPT codes covered if selection criteria are met:
|
95076 |
Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); initial 120 minutes of testing |
95079 |
each additional 60 minutes of testing (list separately in addition to code for primary procedure) |
ICD-10 codes covered if selection criteria are met:
|
L27.2 |
Dermatitis due to ingested food |
T50.995+ |
Adverse effect of other drugs, medicaments and biological substances |
T78.00+ – T78.1+ |
Anaphylactic shock due to adverse food reaction |
T78.1+ |
Other adverse food reactions, not elsewhere classified |
Z88.0 – Z88.9 |
Allergy status to drugs, medicaments and biological substances |
RAST, MAST, FAST, ELISA, ImmunoCAP when percutaneous testing of IgE-mediated allergies cannot be done :
|
CPT codes covered if selection criteria are met:
|
83516 |
Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or semiquantitative; multiple step method |
83518 |
single step method (e.g., reagent strip) |
83519 |
Immunoassay, analyte quantitative; by radiopharmaceutical technique (e.g., RIA) |
83520 |
not otherwise specified |
86003 |
Allergen specific IgE; quantitative or semi-quantitative, each allergen [covered for up to 40 in vitro IgE antibody tests for inhalant allergies and 12 tests for food and other allergies] |
86005 |
qualitative, multi-allergen screen (dipstick, paddle or disk) [covered for up to 40 in vitro IgE antibody tests for inhalant allergies and 12 tests for food and other allergies] |
86008 |
Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each [covered for up to 40 in vitro IgE antibody tests for inhalant allergies and 12 tests for food and other allergies] |
ICD-10 codes covered if selection criteria are met:
|
B44.81 |
Allergic bronchpulmonary aspergillosis |
B65.0 – B83.9 |
Helminthiases [parasitic diseases] |
B85.0 – B89 |
Pediculosis, acariasis and other infestations [parasitic diseases] |
F43.0 |
Acute stress reaction [uncooperative patients] |
F70 – F79 |
Intellectual disabilities [uncooperative patients] |
F84.0 – F84.9 |
Pervasive developmental disorders [uncooperative patients] |
F90.0 – F90.9 |
Attention-deficit hyperactivity disorders [uncooperative patients] |
F91.0 – F91.9 |
Conduct disorders [uncooperative patients] |
J30.1 – J30.9 |
Allergic rhinitis |
L20.0 – L30.9 |
Dermatitis and eczema |
L50.0 |
Allergic urticaria |
L50.3 |
Dermatographic urticarial [dermatographism] |
L85.0 |
Acquired ichthyosis |
Q80.0 – Q80.9 |
Congenital ichthyosis |
T50.995+ |
Adverse effect of other drugs, medicaments and biological substances |
T63.001+ – T63.94x+ |
Toxic effect of contact with venomous animals and plants |
T78.00+ – T78.09+ |
Anaphylactic shock due to adverse food reaction |
T78.1+ |
Other adverse food reactions, not elsewhere classified [except Alpha gal allergy testing for meat allergy] |
T88.6xx+ |
Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered [risk of anaphylaxis from skin testing] |
Total Serum IgE:
|
CPT codes covered if selection criteria are met:
|
82785 |
Gammaglobulin; IgE |
ICD-10 codes covered if selection criteria are met:
|
B44.81 |
Allergic bronchopulmonary aspergillosis |
Lymphocyte transformation tests:
|
CPT codes covered if selection criteria are met:
|
86353 |
Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis [not covered for in-vitro metal allergy testing] |
ICD-10 codes covered if selection criteria are met:
|
B37.0 |
Candidal stomatitis |
B37.83 |
Candidal cheilitis |
C37.0 |
Malignant neoplasm of thymus |
D15.0 |
Benign neoplasm of thymus |
D81.0 – D81.9 |
Combined immunodeficiencies |
D82.0 |
Wiskott-Alrich syndrome |
D82.1 |
DiGeorge’s syndrome |
D83.0 – D83.9 |
Common variable immunodeficiency |
T56.7+ |
Toxic effects of beryllium and its compounds |
Alpha-gal allergy (meat allergy) testing:
|
CPT codes covered if selection criteria are met:
|
86003 |
Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each |
ICD-10 codes covered if selection criteria are met:
|
L50.0 – L50.9 |
Urticaria |
T78.2XXA – T78.2XXS |
Anaphylactic shock, unspecified |
T78.3XXA – T78.3XXS |
Angioneurotic edema |
T80.51XA – T80.59XS |
Anaphylactic reaction due to serum |
R10.0 – R10.13, R10.3 – R10.9 |
Abdominal pain |
R11.10 – R11.14 |
Vomiting |
R55 |
Syncope and collapse |
Z91.018 |
Allergy to other foods [meat allergy] |
Tests considered experimental and investigational for routine allergy testing:
|
CPT codes not covered for indications listed in the CPB:
|
Basophil activation test (BAT), Genetic testing for food allergy, Lymphocyte or basophil phenotyping for food allergy, infinite allergy lab’s fast allergy sensitivity test (FAST) panel – no specific code |
82784 |
Gammaglobulin (immunoglobulin) IgA, IgD, IgG, IgM, each |
82787 |
Gammaglobulin (immunoglobulin); immunoglobulin subclasses (eg, IgG1, 2, 3, or 4), each [not covered for IgG4 testing] |
84238 |
Receptor assay; non-endocrine (specify receptor) [cytokine and cytokine assay] |
84600 |
Volatiles (eg, acetic anhydride, diethylether) |
86001 |
Allergen specific IgG quantitative or semi-quantitative, each allergen |
86003 |
Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each. [testing for food-specific IgE to identify food triggers of FPIES] |
86015 |
Actin (smooth muscle) antibody (ASMA), each |
86021 |
Antibody identification; leukocyte antibodies |
86036 |
Antineutrophil cytoplasmic antibody (ANCA); screen, each antibody |
86037 |
titer, each antibody |
86140 |
C-reactive protein |
86160 |
Complement; antigen, each component |
86161 |
functional activity, each component |
86162 |
total hemolytic (CH50) |
86243 |
Fc receptor |
86332 |
Immune complex assay |
86343 |
Leukocyte histamine release test (LHR) |
86352 |
Cellular function assay involving stimulation (eg, mitogen or antigen) and detection of biomarker (EG, ATP) [anti-IgE receptor antibody testing] |
86485 |
Skin test; candida |
86628 |
Antibody; candida |
88184 |
Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker [anti-IgE receptor antibody testing] |
88185 |
each additional marker (List separately in addition to code for first marker) [anti-IgE receptor antibody testing] |
88341 |
Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) |
88342 |
Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure |
88344 |
Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure |
88346 |
Immunofluorescence, per specimen; initial single antibody stain procedure |
95060 |
Ophthalmic mucous membrane tests |
95065 |
Direct nasal mucous membrane test |
95831 |
Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk |
95832 |
hand, with or without comparison with normal side |
95833 |
total evaluation of body, excluding hands |
95834 |
total evaluation of body, including hands |
HCPCS codes not covered for indications listed in the CPB:
|
K1026 |
Mechanical allergen particle barrier/inhalation filter, cream, nasal, topical |
Mediator Release Test and Cytotoxic food testing (Bryans Test, ACT):
|
CPT codes not covered for indications listed in the CPB:
|
83516 |
Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or semiquantitative; multiple step method |
83518 |
single step method (e.g., reagent strip) |
83519 |
Immunoassay, analyte quantitative; by radiopharmaceutical technique (e.g., RIA) |
83520 |
not otherwise specified |
86258 |
Gliadin (deamidated) (DGP) antibody, each immunoglobulin (Ig) class |
86364 |
Tissue transglutaminase, each immunoglobulin (Ig) class |
86596 |
Voltage-gated calcium channel antibody, each |
86807 |
Serum screening for cytotoxic percent reactive antibody (PRA); standard method |
86808 |
quick method |
Allergenex testing:
|
CPT codes not covered for indications listed in the CPB:
|
Allergenex testing – no specific code:
|
ICD-10 codes not covered for indications listed in the CPB:
|
F90.0 – F90.9 |
Attention-deficit hyperactivity disorders |
G43.001 – G43.919 |
Migraine |
G44.001 – G44.89 |
Other headache syndromes |
J30.1 – J30.9 |
Allergic rhinitis |
J31.0 – J31.2 |
Chronic rhinitis, nasopharyngitis and pharyngitis |
J32.0 – J32.9 |
Chronic sinusitis |
K21.0 – K21.9 |
Gastro-esophageal reflux disease |
K50.00 – K50.919 |
Crohn’s disease [regional enteritis] |
K51.00 – K51.919 |
Ulcerative colitis |
K52.21 |
Food protein-induced enterocolitis syndrome |
K58.0 – K58.9 |
Irritable bowel syndrome |
L20.0 – L30.9 |
Dermatitis and eczema |
L50.0 – L50.9 |
Urticaria |
M05.00 – M14.89 |
Inflammatory polyarthropathies |
M79.0 – M79.5 |
Other and unspecified soft tissue disorders, not elsewhere classified |
N95.1 |
Menopausal and female climacteric states |
R53.0 – R53.83 |
Malaise and fatigue |
R04.0 – R04.1, R06.5 – R06.7, R06.89, R07.0, R09.81 – R09.89, R19.6, R22.0 – R22.1, R47.01 – R47.9, R48.0 – R48.9, R49.0 – R49.9, R51, R68.84 |
Symptoms and signs involving the head and neck |
T78.1xxA – T78.1xxS |
Other adverse food reactions, not elsewhere classified |
There is no specific code for Cliffords Material Reactivity Testing:
|
Allergy immunotherapy:
|
CPT codes covered if selection criteria are met:
|
95115 – 95170, 95199 |
Professional services for allergen immunotherapy (for rapid desensitization see below) [except home administration] [not covered for intradermal grass pollen immunotherapy] [not covered for intranasal immunotherapy] |
CPT codes not covered for indications listed in the CPB:
|
Oral immunotherapy – no specific code:
|
97810 – 97814 |
Acupuncture |
HCPCS codes covered if selection criteria are met:
|
J0171 |
Injection, adrenalin, epinephrine, 0.1 mg |
Other HCPCS codes related to the CPB:
|
J2357 |
Injection, omalizumab, 5 mg |
ICD-10 codes covered if selection criteria are met:
|
H10.10 – H10.13 |
Acute atopic conjunctivitis |
H10.44 |
Vernal conjunctivitis |
H10.45 |
Other chronic allergic conjunctivitis |
J30.1 – J30.9 |
Allergic rhinitis |
J45.20 – J45.998 |
Asthma [covered for allergic (extrinsic)] [not covered for intrinsic (non-allergic)] |
L20.89 |
Other atopic dermatitis [dust mite] |
T63.001+ – T63.94x+ |
Toxic effect of contact with venomous animals and plants |
Z91.030 – Z91.038 |
Insect allergy status [bees, hornets, wasps, and fire ants] |
ICD-10 codes not covered for indications listed in the CPB:
|
G43.001 – G43.919 |
Migraine |
L25.4 |
Unspecified contact dermatitis due to food in contact with skin |
L27.2 |
Dermatitis due to ingested food |
L50.8 |
Other urticaria [chronic] |
T78.3+ |
Angioneurotic edema |
Other Treatments:
|
Rapid desensitization:
|
CPT codes covered if selection criteria are met:
|
95180 |
Rapid desensitization procedure, each hour (e.g., insulin, penicillin, equine serum) |
ICD-10 codes covered if selection criteria are met:
|
J30.0 – J30.9 |
Allergic rhinitis |
S00.06XA – S00.06XS, S00.261A – S00.269S, S00.36xA – S00.36xS, S00.461A – S00.469S, S00.561A – S00.562S, S00.86xA – S00.86xS, S00.96xA – S00.96xS, S10.16XA – S10.16XS, S10.86xA – S10.86xS, S10.96xA – S10.96xS, S20.161A – S20.169S, S20.361A – S20.369S, S20.461A – S20.469S, S20.96XA – S20.96XS, S30.860A – S30.867S, S40.261A – S40.269S, S40.861A – S40.869S, S50.361A – S50.369S, S50.861A – S50.869S, S60.361A – S60.369S, S60.460A – S60.469S, S60.561A – S60.569S, S60.861A – S60.869S, S70.261A – S70.269S, S70.361A – S70.369S, S80.261A – S80.269S, S80.861A – S80.869S, S90.461A – S90.466S, S90.561A – S90.569S, S90.861A – S90.869S |
Insect bites |
T36.0X1A – T50.996S |
Poisoning by, adverse effect of and underdosing of drugs, medicaments and biologic substances |
T63.421A – T63.484S |
Toxic effect of venom of other arthropod |
Z88.0 – Z88.9 |
Allergy status to drugs, medicaments and biological substances |
Z91.030 – Z91.038 |
Allergy to insects |
Chemical cautery of nasal mucosa:
|
CPT codes not covered for indications listed in the CPB:
|
Chemical cautery of nasal mucosa – no specific code:
|
ICD-10 codes not covered for indications listed in the CPB:
|
J30.1 – J30.9 |
Allergic rhinitis |
Subcutaneous or Intramuscular (IM) steroids:
|
Other CPT codes related to the CPB:
|
96372 |
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular |
HCPCS codes not covered if selection criteria are met:
|
J0702 |
Injection, betamethasone acetate 3mg and betamethasone sodium phosphate 3mg |
J1020 |
Injection, methylprednisolone acetate, 20 mg |
J1030 |
Injection, methylprednisolone acetate, 40 mg |
J1040 |
Injection, methylprednisolone acetate, 80 mg |
J1094 |
Injection, dexamethasone acetate, 1 mg |
J1100 |
Injection, dexamethasone sodium phosphate, 1mg |
J1700 |
Injection, hydrocortisone acetate, up to 25 mg |
J1710 |
Injection, hydrocortisone sodium phosphate, up to 50 mg |
J1720 |
Injection, hydrocortisone sodium succinate, up to 100 mg |
J2650 |
Injection, prednisolone acetate, up to 1 ml |
J2920 |
Injection, methylprednisolone sodium succinate, up to 40 mg |
J2930 |
Injection, methylprednisolone sodium succinate, up to 125 mg |
J3300 |
Injection, triamcinolone acetonide, preservative free, 1 mg |
J3301 |
Injection, triamcinolone acetonide, not otherwise specified, 10 mg |
J3302 |
Injection, triamcinolone diacetate, per 5mg |
J3303 |
Injection, triamcinolone hexacetonide, per 5mg |
ICD-10 codes not covered if selection criteria are met:
|
J01.00 – J01.91 |
Acute sinusitis, unspecified |
J30.1 – J30.9 |
Allergic rhinitis, unspecified |
Aspirin Desensitization:
|
No specific code |
Oralair, Grastek and Ragwitek:
|
ICD-10 codes covered if selection criteria are met::
|
J30.1 |
Allergic rhinitis due to pollen |
Autologous whole blood or autologous serum acupoint:
|
CPT codes not covered for indications listed in the CPB:
|
Autologous whole blood, autologous serum acupoint – no specific code |
ICD-10 codes not covered for indications listed in the CPB:
|
L50.8 |
Other urticaria |