ALLERGY CODING GUIDELINES AND BILLING ESSENTIALS

Physicians deal with an influx of patients almost all year round with allergy-related complaints caused either by the change in temperature, weather, environmental factors, animal fur/dandruff or with the consumption of certain foods, medications or even an insect sting. While they provide urgent medical care to their patients, they also need to ensure adequate documentation of the patient’s condition against appropriate allergy coding to ensure compliance and payment for the care they deliver.

Managing an allergy practice can be taxing and difficult. However, the key to establishing and maintaining an active, financially thriving medical practice for an allergist lies in a thorough understanding of the current reimbursement system and allergy coding guidelines.

At present, many practices are being subject to increased scrutiny and pressure by third-party payers to provide the most cost-efficient healthcare services. In this environment, it is imperative that healthcare providers, especially allergists, focus on the best possible allergy coding and allergy billing practices to avoid added expenses and any reimbursement issues.

Allergy Coding for Testing Services

An allergy test is an examination of the patient’s body performed by a trained allergist to identify the allergens that are affecting them. Allergy testing is usually the first step in the immunotherapy process taken by a physician towards tackling the patient’s allergies to identify potential allergens affecting the patient. The most preferred method for allergy testing is skin testing, which cannot be billed more than twice per each different antigen.

These tests may be performed by a physician or by non-physician personnel such as nurses and medical assistants. All these tests are assigned a certain level of supervision requirement in the Medicare Physician Fee Schedule (MPFS) database according to the level of potential risks involved in the diagnostic service. These levels of supervision are:

• General Supervision: The low-risk procedure takes place under the physician’s overall control and management responsibility but the physician’s presence is not required. The training of the non-physician provider and the supply of necessary equipment to perform the procedure is still the physician’s responsibility. 
• Direct Supervision: The moderate risk procedure is performed in the presence of the physician who is in the office suite. However, the physician does not need to be in the same room as where the test is being performed. The allergy coding guidelines for direct supervision services are the same as incident-to services.
• Personal Supervision: The test of comparatively greater risk has to be performed under the supervision of the physician who must be in the same room where the test is being performed.

A ‘1’ in the MFPS database Diagnostic Supervision field indicates that the test requires general supervision. Similarly, a ‘2’ in the field indicates that the allergy code requires direct supervision and a ‘3’ represents the fact that the procedure requires personal supervision.

Allergy Coding Guidelines for Testing

It is important to keep in mind that although the diagnostic test may not be performed by the physician, the results have to be reported and interpreted by a physician. Standard medical practice and allergy coding guidelines dictate that two different codes of allergy immunotherapy and allergy testing should not be reported together unless both allergy testing and immunotherapy are performed on the same day.

Allergy coding for testing services involves the use of codes 95004 through 95078 which are all established codes in the MFPS database as single tests. This means that the frequency of the same test performed on the same patient must be documented on the allergy billing claim. For example, if an allergist performs 10 intracutaneous tests, the clinically appropriate allergy billing code would be documented along with a ‘10’ in the ‘units’ field to indicate that ten units of the same test were conducted. The total payment for reimbursement would be calculated by multiplying the number of units of the test by the payment for one test.

In addition, the interpretation and reporting of the tests are included as part of these testing codes. E/M service codes may be charged in conjunction with allergy coding if the service is significant and separately identifiable. In such cases, modifier 25 is applied. However, if the history and examination are only taken to enable testing, the E&M code cannot be billed separately.

Common Allergy Codes for Testing

Here are some of the most common allergy codes for testing that require direct supervision:

• CPT 95004 – Percutaneous tests for non-biological/non-venom allergenic extracts with an immediate-type reaction
• CPT 95024 – Intracutaneous (intradermal) tests for non-biological/non-venom allergenic extracts for airborne with an immediate-type reaction OR 1 stick antigen
• CPT 95027 – Sequential and incremental testing for airborne allergens with an immediate-type reaction OR multiple sticks /antigen
• CPT 95028 – Intracutaneous tests with allergenic extracts and a delayed-type reaction including reading, specify no of test (24-72 hours after administration)
• CPT 95044 – Patch OR application tests
• CPT 95056 – Photo tests
• CPT 95052 – Photo patch tests

When CPT 95056 is performed with CPT 95044, only allergy code 95056 is to be reported. Furthermore, if CPT 95052 is performed with 95056 and 95044, only CPT 95052 (photo patch testing) is to be reported.

Code 95017 is coded when any combination of percutaneous, intracutaneous, or sequential and incremental testing is performed with venoms. Similarly, CPT 95018 is documented when any combination of these tests is performed with drugs or biological allergenic extracts.

Allergy coding’s requiring personal supervision include:

• CPT 95060 – Ophthalmic mucous membrane testing.
• CPT 95070 – Inhalation bronchial challenge testing with methacholine, histamine, or similar substances.

Immunotherapy Coding

Once appropriate allergy testing has allowed the physician to determine what the patient is allergic to, it is time to treat them using immunotherapy to increase the patient’s ability to resist the allergen. Allergy coding for immunotherapy services includes the codes 95115-95199.

CPT code 95165 is documented for the preparation of non-venom antigens dose vials. When allergy billing for code 95165, the number of doses (1 dose = 1 cc aliquot from a multi-dose vial) should be reported with a maximum of ten doses per vial allowed to bill Medicare.

Allergy coding for the preparation of stinging insect venom includes the use of codes 95145-95149 and 95170 depending upon the type of venom prepared. These are codes for single doses which require specification of the number of doses provided. These codes can be reported together if more than one venom is provided to the patient.

Coding for the Administration of Immunotherapy

Once the immunotherapy serum has been prepared, the physician has to administer the doses to the patient in the form of allergy shots. One of two injection codes is used to report the administration of allergy immunotherapy in allergy coding.

• 95115 – single injection
• 95117 – more than one injection

95117 is not an add-on code but instead, a separate code from 95115. Allergy billing for codes 95115 and 95117 together is not possible and can never be reported together.

See Also: Patient Journey Mapping: What You Need To Know

Bottom Line

There is no denying that while you provide care to your patients, you also need to focus on the administrative and operational aspects of your practice.  Unfortunately, most medical schools and colleges provide little to no training on managing these functions. However, to keep your practice thriving, it is essential that allergists have a thorough understanding of the allergy coding system and know how to record the services they provide.