Notification

Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])


Notification Issue Date: 04/02/2019



Policy Attachment


Attachment to Policy # 07.07.03m


Attachment:A

Policy #:07.07.03m

Description:ICD-10 Diagnosis Code Number(s) and Narrative(s)

Title:Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])


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.



ICD-10 Diagnosis Code Number(s) and Narrative(s)

C44.00 Unspecified malignant neoplasm of skin of lip

C44.01 Basal cell carcinoma of skin of lip

C44.02 Squamous cell carcinoma of skin of lip

C44.09 Other specified malignant neoplasm of skin of lip

C44.101 Unspecified malignant neoplasm of skin of unspecified eyelid, including canthus

C44.1021 Unspecified malignant neoplasm of skin of right upper eyelid, including canthus

C44.1022 Unspecified malignant neoplasm of skin of right lower eyelid, including canthus

C44.1091 Unspecified malignant neoplasm of skin of left upper eyelid, including canthus

C44.1092 Unspecified malignant neoplasm of skin of left lower eyelid, including canthus

C44.111 Basal cell carcinoma of skin of unspecified eyelid, including canthus

C44.1121 Basal cell carcinoma of skin of right upper eyelid, including canthus

C44.1122 Basal cell carcinoma of skin of right lower eyelid, including canthus

C44.1191 Basal cell carcinoma of skin of left upper eyelid, including canthus

C44.1192 Basal cell carcinoma of skin of left lower eyelid, including canthus

C44.121 Squamous cell carcinoma of skin of unspecified eyelid, including canthus

C44.1221 Squamous cell carcinoma of skin of right upper eyelid, including canthus

C44.1222 Squamous cell carcinoma of skin of right lower eyelid, including canthus

C44.1291 Squamous cell carcinoma of skin of left upper eyelid, including canthus

C44.1292 Squamous cell carcinoma of skin of left lower eyelid, including canthus

C44.191 Other specified malignant neoplasm of skin of unspecified eyelid, including canthus

C44.1921 Other specified malignant neoplasm of skin of right upper eyelid, including canthus

C44.1922 Other specified malignant neoplasm of skin of right lower eyelid, including canthus

C44.1991 Other specified malignant neoplasm of skin of left upper eyelid, including canthus

C44.1992 Other specified malignant neoplasm of skin of left lower eyelid, including canthus

C44.201 Unspecified malignant neoplasm of skin of unspecified ear and external auricular canal

C44.202 Unspecified malignant neoplasm of skin of right ear and external auricular canal

C44.209 Unspecified malignant neoplasm of skin of left ear and external auricular canal

C44.211 Basal cell carcinoma of skin of unspecified ear and external auricular canal

C44.212 Basal cell carcinoma of skin of right ear and external auricular canal

C44.219 Basal cell carcinoma of skin of left ear and external auricular canal

C44.221 Squamous cell carcinoma of skin of unspecified ear and external auricular canal

C44.222 Squamous cell carcinoma of skin of right ear and external auricular canal

C44.229 Squamous cell carcinoma of skin of left ear and external auricular canal

C44.291 Other specified malignant neoplasm of skin of unspecified ear and external auricular canal

C44.292 Other specified malignant neoplasm of skin of right ear and external auricular canal

C44.299 Other specified malignant neoplasm of skin of left ear and external auricular canal

C44.300 Unspecified malignant neoplasm of skin of unspecified part of face

C44.301 Unspecified malignant neoplasm of skin of nose

C44.309 Unspecified malignant neoplasm of skin of other parts of face

C44.310 Basal cell carcinoma of skin of unspecified parts of face

C44.311 Basal cell carcinoma of skin of nose

C44.319 Basal cell carcinoma of skin of other parts of face

C44.320 Squamous cell carcinoma of skin of unspecified parts of face

C44.321 Squamous cell carcinoma of skin of nose

C44.329 Squamous cell carcinoma of skin of other parts of face

C44.390 Other specified malignant neoplasm of skin of unspecified parts of face

C44.391 Other specified malignant neoplasm of skin of nose

C44.399 Other specified malignant neoplasm of skin of other parts of face

C44.40 Unspecified malignant neoplasm of skin of scalp and neck

C44.41 Basal cell carcinoma of skin of scalp and neck

C44.42 Squamous cell carcinoma of skin of scalp and neck

C44.49 Other specified malignant neoplasm of skin of scalp and neck

C44.500 Unspecified malignant neoplasm of anal skin

C44.501 Unspecified malignant neoplasm of skin of breast

C44.509 Unspecified malignant neoplasm of skin of other part of trunk

C44.510 Basal cell carcinoma of anal skin

C44.511 Basal cell carcinoma of skin of breast

C44.519 Basal cell carcinoma of skin of other part of trunk

C44.520 Squamous cell carcinoma of anal skin

C44.521 Squamous cell carcinoma of skin of breast

C44.529 Squamous cell carcinoma of skin of other part of trunk

C44.590 Other specified malignant neoplasm of anal skin

C44.591 Other specified malignant neoplasm of skin of breast

C44.599 Other specified malignant neoplasm of skin of other part of trunk

C44.601 Unspecified malignant neoplasm of skin of unspecified upper limb, including shoulder

C44.602 Unspecified malignant neoplasm of skin of right upper limb, including shoulder

C44.609 Unspecified malignant neoplasm of skin of left upper limb, including shoulder

C44.611 Basal cell carcinoma of skin of unspecified upper limb, including shoulder

C44.612 Basal cell carcinoma of skin of right upper limb, including shoulder

C44.619 Basal cell carcinoma of skin of left upper limb, including shoulder

C44.621 Squamous cell carcinoma of skin of unspecified upper limb, including shoulder

C44.622 Squamous cell carcinoma of skin of right upper limb, including shoulder

C44.629 Squamous cell carcinoma of skin of left upper limb, including shoulder

C44.691 Other specified malignant neoplasm of skin of unspecified upper limb, including shoulder

C44.692 Other specified malignant neoplasm of skin of right upper limb, including shoulder

C44.699 Other specified malignant neoplasm of skin of left upper limb, including shoulder

C44.701 Unspecified malignant neoplasm of skin of unspecified lower limb, including hip

C44.702 Unspecified malignant neoplasm of skin of right lower limb, including hip

C44.709 Unspecified malignant neoplasm of skin of left lower limb, including hip

C44.711 Basal cell carcinoma of skin of unspecified lower limb, including hip

C44.712 Basal cell carcinoma of skin of right lower limb, including hip

C44.719 Basal cell carcinoma of skin of left lower limb, including hip

C44.721 Squamous cell carcinoma of skin of unspecified lower limb, including hip

C44.722 Squamous cell carcinoma of skin of right lower limb, including hip

C44.729 Squamous cell carcinoma of skin of left lower limb, including hip

C44.791 Other specified malignant neoplasm of skin of unspecified lower limb, including hip

C44.792 Other specified malignant neoplasm of skin of right lower limb, including hip

C44.799 Other specified malignant neoplasm of skin of left lower limb, including hip

C44.80 Unspecified malignant neoplasm of overlapping sites of skin

C44.81 Basal cell carcinoma of overlapping sites of skin

C44.82 Squamous cell carcinoma of overlapping sites of skin

C44.89 Other specified malignant neoplasm of overlapping sites of skin

C44.90 Unspecified malignant neoplasm of skin, unspecified

C44.91 Basal cell carcinoma of skin, unspecified

C44.92 Squamous cell carcinoma of skin, unspecified

C44.99 Other specified malignant neoplasm of skin, unspecified

D04.0 Carcinoma in situ of skin of lip

D04.10 Carcinoma in situ of skin of unspecified eyelid, including canthus

D04.111 Carcinoma in situ of skin of right upper eyelid, including canthus

D04.112 Carcinoma in situ of skin of right lower eyelid, including canthus

D04.121 Carcinoma in situ of skin of left upper eyelid, including canthus

D04.122 Carcinoma in situ of skin of left lower eyelid, including canthus

D04.20 Carcinoma in situ of skin of unspecified ear and external auricular canal

D04.21 Carcinoma in situ of skin of right ear and external auricular canal

D04.22 Carcinoma in situ of skin of left ear and external auricular canal

D04.30 Carcinoma in situ of skin of unspecified part of face

D04.39 Carcinoma in situ of skin of other parts of face

D04.4 Carcinoma in situ of skin of scalp and neck

D04.5 Carcinoma in situ of skin of trunk

D04.60 Carcinoma in situ of skin of unspecified upper limb, including shoulder

D04.61 Carcinoma in situ of skin of right upper limb, including shoulder

D04.62 Carcinoma in situ of skin of left upper limb, including shoulder

D04.70 Carcinoma in situ of skin of unspecified lower limb, including hip

D04.71 Carcinoma in situ of skin of right lower limb, including hip

D04.72 Carcinoma in situ of skin of left lower limb, including hip

D04.8 Carcinoma in situ of skin of other sites

D04.9 Carcinoma in situ of skin, unspecified

L57.0 Actinic keratosis

Version Effective Date: 07/01/2019
Version Issued Date: 07/01/2019
Version Reissued Date: N/A

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