Notification Issue Date:

Policy Attachment

Attachment to Policy # 07.07.02j


Policy #:07.07.02j

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.

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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