Navigating the complexities of medical billing and coding is crucial, especially when it comes to specialized services like allergy testing. For healthcare providers and billing professionals, understanding the correct diagnosis codes and billing procedures for allergy testing is essential for accurate claims and optimal reimbursement. This guide provides a comprehensive overview of allergy testing diagnosis codes, billing guidelines, and crucial considerations for coding these services effectively, primarily focusing on the standards relevant to the U.S. healthcare system.
Understanding Allergy Testing Billing Guidelines
Accurate billing for allergy testing hinges on adhering to specific guidelines. Evaluation and Management (E/M) codes, when reported alongside allergy testing codes, are only appropriate if a significant, separately identifiable E/M service is performed. According to CPT (Current Procedural Terminology) guidelines, if such an E/M service occurs, it’s essential to use modifier -25 with the E/M code to denote it as a distinct service. Crucially, the medical documentation must clearly support the necessity of this separately identifiable service within the patient’s medical record.
In standard medical practice, allergy testing and allergy immunotherapy are typically not performed on the same day. Consequently, these procedures should not be billed together unless specific circumstances warrant it, such as testing for additional allergens on the same day as immunotherapy. Furthermore, allergy testing becomes an integral part of rapid desensitization kits (CPT code 95180) and should not be reported separately when these kits are utilized.
The Medicare Physician Fee Schedule Database (MPFSDB) establishes fee amounts for allergy testing services billed under codes 95004-95078 for single tests. Therefore, it’s imperative to specify the number of tests performed on the claim form. This ensures accurate payment calculation by Medicare contractors, who multiply the payment for a single test by the quantity of tests reported.
Example Scenario:
Consider a scenario where a physician performs 25 percutaneous tests (scratch, puncture, or prick) using allergenic extracts. In such cases, the physician must bill using code 95004, 95017, or 95018, and explicitly state “25” in the units field of the CMS-1500 form (for both paper and electronic claims). This detailed unit reporting is vital for correct payment processing. For Part B Medicare providers, Box 24G of the 1500 claim form is designated to indicate the actual number of tests performed – one unit for each antigen. For electronic claims (EMC), this number should be entered in the service field.
CPT Codes and Units of Service for Allergy Testing
Interpretation of specific CPT codes, including 95004, 95017, 95018, 95024, 95027, 95028, 95044, 95052, and 95065, directly depends on the number of tests administered. For each test performed, one unit of service should be reported. For instance, if 18 scratch tests are conducted, code 95004, 95017, or 95018 should be reported with 18 units of service. Similarly, 36 tests would necessitate reporting the same codes with 36 units of service.
When photo patch tests (CPT code 95052) are performed alongside patch or application tests during the same session and using the same antigen, only the photo patch testing should be reported. Unbundling these services by reporting both CPT code 95044 (patch or application tests) and CPT code 95056 (photo tests) in addition to CPT code 95052 is not appropriate. If photo testing includes application or patch testing, CPT code 95052 remains the correct code to report, superseding CPT codes 95044 and 95056.
Non-Covered Allergy Testing Services
It’s crucial to be aware of services that are not covered. Medicare, for example, explicitly excludes certain allergy testing services from coverage due to a lack of evidence supporting their effectiveness. These non-covered services include:
a. Sublingual, Intracutaneous, and Subcutaneous Provocative and Neutralization Testing: Medicare does not cover these tests and neutralization therapy for food allergies as of October 31, 1988.
b. Challenge Ingestion Food Testing: This type of testing is not considered reasonable and necessary for diagnosing conditions like rheumatoid arthritis, depression, or respiratory disorders, and therefore is not covered when used for these purposes.
c. Cytotoxic Food Tests: Effective August 5, 1985, cytotoxic leukocyte tests for food allergies are not covered by Medicare due to insufficient evidence regarding their safety and efficacy.
Covered Allergy Testing Services and Medical Necessity
Allergy testing is generally covered when patients present with clinically significant symptoms and conservative therapies have proven ineffective. Covered allergy testing encompasses the performance, evaluation, and interpretation of cutaneous and mucous membrane testing. This also includes the physician’s role in taking a detailed immunologic history, conducting physical examinations, selecting appropriate antigens, and interpreting the test results.
It is important to note that counseling and prescribing treatment following allergy testing should be reported using a separate visit code and should not be included within Evaluation and Management (E/M) services reported for test interpretation and reporting.
Standard skin testing is the preferred method when allergy testing is deemed medically necessary. Each test should be billed as one unit of service per procedure code, and it is advised not to exceed two strengths per unique antigen. The selection and number of antigens tested should be individualized, based on the patient’s medical history and environmental exposures. A visit to an allergist resulting in a diagnosis of specific allergy sensitivity, but not involving immunotherapy, should be coded according to the level of care rendered during the visit.
CPT procedure code 95060 is payable across various places of service, including office, outpatient hospital (both on-campus and off-campus), inpatient hospital, and emergency room settings.
Hospital Inpatient Claims for Allergy Testing
Effective January 1, 2006, CMS (Centers for Medicare & Medicaid Services) distinguishes between single allergy tests (“per test”) and multiple allergy tests (“per visit”) by assigning them to different Ambulatory Payment Classifications (APCs). Single allergy tests are assigned to APC 0381, while multiple allergy tests are maintained under APC 0370. Hospitals are instructed to report charges for CPT codes describing single allergy tests (or where CPT guidelines specify reporting the number of tests) to reflect charges per test rather than per visit. They should bill the appropriate number of units for these CPT codes to accurately represent all tests provided.
Coding Guidelines and NCCI Edits
According to the CMS National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, specific guidelines apply to the coding of allergy testing and immunotherapy. If percutaneous or intracutaneous (intradermal) single tests (CPT codes 95004 or 95024) and “sequential and incremental” tests (CPT codes 95017, 95018, or 95027) are performed on the same date of service, both types of test codes can be reported if they involve different allergens or varying dilutions of the same allergen. The unit of service reported should reflect the number of separate tests conducted. However, a single test and a “sequential and incremental” test for the same dilution of an allergen should not be reported separately on the same date. For example, if a single test for an antigen is positive and subsequent sequential and incremental tests are performed using three additional dilutions of the same antigen, one unit of service for the single test code and three units for the “sequential and incremental” test code can be reported.
Photo patch tests (CPT code 95052) involve applying a patch containing allergenic substances and exposing the skin to light. It is incorrect to unbundle this service by reporting both CPT code 95044 (patch tests) and CPT code 95056 (photo tests) separately, instead of using CPT code 95052.
E/M codes reported with allergy testing or immunotherapy are appropriate only when a significant, separately identifiable service is performed, and modifier 25 should be used in such cases. Generally, allergy testing and immunotherapy are not performed on the same day, as testing typically precedes immunotherapy to identify the specific allergens. CPT codes for allergy testing and immunotherapy are usually not reported together on the same date, unless immunotherapy and testing for additional allergens occur on the same day. Allergen potency (safety) testing prior to immunotherapy administration is considered an inherent part of immunotherapy and should not be separately reported using allergy testing CPT codes. Similarly, allergy testing that is integral to rapid desensitization kits (CPT code 95180) is not separately reportable.
It’s important to remember that HCPCS/CPT codes are subject to Correct Coding Initiative (CCI) edits. CCI edits and guidelines should always be consulted prior to billing Medicare, as they take precedence over general policy guidelines. Understanding and adhering to these detailed coding and billing guidelines is crucial for healthcare providers to ensure accurate and compliant billing practices for allergy testing services.
