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Article-Guidelines-for-Allergy-Testing-Billing

Allergy and Immunology billing requires professional expertise in coding and billing for the services rendered. Different insurance carriers treat allergy testing and medication differently and have an entirely different set of rules for billing for these services. In this article, we shared guidelines for allergy testing billing keeping Medicare billing guidelines as standard. For the accurate selection of codes and services coverage, you have to refer to payer-specific allergy and immunology billing guidelines.

Guidelines for Allergy Testing Billing

  • Evaluation and management (E/M) codes reported with allergy testing are appropriate only if a significant, separately identifiable service is administered. When appropriate, use modifier - 25 with the E/M code, to indicate it as a separately identifiable service. If E/M services are reported, medical documentation of the separately identifiable service should be in the medical record.
  • Allergy testing is not performed on the same day as allergy immunotherapy in standard medical practice. These codes should, therefore, not be reported together. Additionally, the testing becomes an integral part to rapid desensitization kits (CPT code 95180) and would therefore not be reported separately.
  • The allergy testing services can be billed under codes 95004-95078 which are established for single tests. Therefore, the number of tests must be shown on the claim. If a physician performs 25 percutaneous tests (scratch, puncture, or prick) with allergenic extract, the physician must bill code 95004, 95017, or 95018 and specify 25 in the units field of Form CMS1500. Part B providers indicate the number of tests (one for each antigen) in Box 24G of the 1500 claim form. Out of code range 95004 – 95078, use the code number which includes the number of tests that were performed and enter 1 unit for each test performed. For example, if 18 scratch tests are done, code 95004, 95017, or 95018 with 18-like services. If 36 are done, code 95004, 95017, or 95018 with 36-like services.
  • When photo patch tests (e.g. CPT code 95052) are performed (same antigen/same session) with patch or application tests, only the photo patch testing should be reported. Additionally, if photo testing is performed including application or patch testing, the code for photo patch testing (CPT code 95052) is to be reported, not CPT code 95044 (patch or application tests) and CPT code 95056 (photo tests). Allergy testing is covered when clinically significant symptoms exist and conservative therapy has failed. Allergy testing includes the performance, evaluation, and reading of cutaneous and mucous membrane testing.
  • Standard skin testing is the preferred method when allergy testing is necessary. Each test should be billed as one unit of service per procedure code, not to exceed two strengths per each unique antigen. Histamine and saline controls are appropriate and can be billed as two antigens. The number of antigens should be individualized for each patient based on history and environmental exposure.
  • Non-covered testing includes, but are not limited to Sublingual Intracutaneous and subcutaneous Provocative and Neutralization Testing; Challenge Ingestion Food Testing; and Cytotoxic Food Tests.
  • If percutaneous or intracutaneous (intradermal) single test (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 the ‘sequential and incremental’ test and single test codes may be reported if the tests are for different allergens or different dilutions of the same allergen. The unit of service to report is the number of separate tests. 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 of service. For example, if the single test for an antigen is positive and the physician proceeds to ‘sequential and incremental’ tests with three additional different dilutions of the same antigen, the physician may report one unit of service for the single test code and three units of service for the ‘sequential and incremental’ test code.
  • Photo patch tests (CPT code 95052) consist of applying a patch(s) containing allergenic substance(s) (same antigen/same session) to the skin and exposing the skin to light. Physicians should not unbundle this service by reporting both CPT code 95044 (patch or application tests) plus CPT code 95056 (photo tests) rather than CPT code 95052.
  • In general allergy testing is not performed on the same day as allergy immunotherapy in standard medical practice. Allergy testing is performed prior to immunotherapy to determine the offending allergens. CPT codes for allergy testing and immunotherapy are generally not reported on the same date of service unless the physician provides allergy immunotherapy and testing for additional allergens on the same day. Physicians should not report allergy testing CPT codes for allergen potency (safety) testing prior to the administration of immunotherapy. Confirmation of the appropriate potency of an allergen vial for immunotherapy is an inherent component of immunotherapy. Additionally, allergy testing is an integral component of rapid desensitization kits (CPT code 95180) and is not separately reportable.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. We referred CMS document to explain the guidelines for allergy testing billing. If you need assistance in Allergy and Immunology billing then call us at: 888-357-3226 or email us at: info@medicalbillersandcoders.com.

Reference: Billing and Coding Guidelines for Allergy Testing


Published By - Medical Billers and Coders
Published Date - Jan-12-2023 Back

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