Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA07.002c


Attachment:A

Policy #:MA07.002c

Description:ICD-10-CM codes

Title:Ultraviolet Light Therapy for the Treatment of Dermatological Conditions


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.


    A67.2 Late lesions of pinta

    C84.00 Mycosis fungoides, unspecified site

    C84.01 Mycosis fungoides, lymph nodes of head, face, and neck

    C84.02 Mycosis fungoides, intrathoracic lymph nodes

    C84.03 Mycosis fungoides, intra-abdominal lymph nodes

    C84.04 Mycosis fungoides, lymph nodes of axilla and upper limb

    C84.05 Mycosis fungoides, lymph nodes of inguinal region and lower limb

    C84.06 Mycosis fungoides, intrapelvic lymph nodes

    C84.07 Mycosis fungoides, spleen

    C84.08 Mycosis fungoides, lymph nodes of multiple sites

    C84.09 Mycosis fungoides, extranodal and solid organ sites

    C84.10 Sezary disease, unspecified site

    C84.11 Sezary disease, lymph nodes of head, face, and neck

    C84.12 Sezary disease, intrathoracic lymph nodes

    C84.13 Sezary disease, intra-abdominal lymph nodes

    C84.14 Sezary disease, lymph nodes of axilla and upper limb

    C84.15 Sezary disease, lymph nodes of inguinal region and lower limb

    C84.16 Sezary disease, intrapelvic lymph nodes

    C84.17 Sezary disease, spleen

    C84.18 Sezary disease, lymph nodes of multiple sites

    C84.19 Sezary disease, extranodal and solid organ sites

    C86.6 Primary cutaneous CD30-positive T-cell proliferations

    D89.811 Chronic graft-versus-host disease

    D89.812 Acute on chronic graft-versus-host disease

    H02.731 Vitiligo of right upper eyelid and periocular area

    H02.732 Vitiligo of right lower eyelid and periocular area

    H02.733 Vitiligo of right eye, unspecified eyelid and periocular area

    H02.734 Vitiligo of left upper eyelid and periocular area

    H02.735 Vitiligo of left lower eyelid and periocular area

    H02.736 Vitiligo of left eye, unspecified eyelid and periocular area

    H02.739 Vitiligo of unspecified eye, unspecified eyelid and periocular area

    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

    L26 Exfoliative dermatitis

    L28.0 Lichen simplex chronicus

    L28.1 Prurigo nodularis

    L29.8 Other pruritus

    L29.9 Pruritus, unspecified

    L30.0 Nummular dermatitis

    L30.1 Dyshidrosis [pompholyx]

    L30.2 Cutaneous autosensitization

    L30.5 Pityriasis alba

    L30.8 Other specified dermatitis

    L30.9 Dermatitis, unspecified

    L40.0 Psoriasis vulgaris

    L40.1 Generalized pustular psoriasis

    L40.2 Acrodermatitis continua

    L40.3 Pustulosis palmaris et plantaris

    L40.4 Guttate psoriasis

    L40.50 Arthropathic psoriasis, unspecified

    L40.51 Distal interphalangeal psoriatic arthropathy

    L40.52 Psoriatic arthritis mutilans

    L40.53 Psoriatic spondylitis

    L40.54 Psoriatic juvenile arthropathy

    L40.59 Other psoriatic arthropathy

    L40.8 Other psoriasis

    L40.9 Psoriasis, unspecified

    L41.0 Pityriasis lichenoides et varioliformis acuta

    L41.1 Pityriasis lichenoides chronica

    L41.3 Small plaque parapsoriasis

    L41.4 Large plaque parapsoriasis

    L41.5 Retiform parapsoriasis

    L41.8 Other parapsoriasis

    L41.9 Parapsoriasis, unspecified

    L42 Pityriasis rosea

    L43.0 Hypertrophic lichen planus

    L43.1 Bullous lichen planus

    L43.2 Lichenoid drug reaction

    L43.3 Subacute (active) lichen planus

    L43.8 Other lichen planus

    L43.9 Lichen planus, unspecified

    L56.0 Drug phototoxic response

    L56.1 Drug photoallergic response

    L56.2 Photocontact dermatitis [berloque dermatitis]

    L56.3 Solar urticaria

    L56.4 Polymorphous light eruption

    L56.5 Disseminated superficial actinic porokeratosis (DSAP)

    L56.8 Other specified acute skin changes due to ultraviolet radiation

    L56.9 Acute skin change due to ultraviolet radiation, unspecified

    L57.1 Actinic reticuloid

    L57.5 Actinic granuloma

    L63.0 Alopecia (capitis) totalis

    L63.1 Alopecia universalis

    L63.2 Ophiasis

    L63.8 Other alopecia areata

    L63.9 Alopecia areata, unspecified

    L80 Vitiligo

    L90.0 Lichen sclerosus et atrophicus

    L92.0 Granuloma annulare

    L94.0 Localized scleroderma [morphea]

    L94.1 Linear scleroderma

    Q82.2 Congenital cutaneous mastocytosis


Version Effective Date: 10/01/2017
Version Issued Date: 09/29/2017
Version Reissued Date: 12/18/2019

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