Coding Guidelines for Allergy Testing

Coding Guidelines for Allergy Testing

Running an allergy practice can be exhausting and as allergy coding offers unique set of challenges. The key to establishing and maintaining an active, financially thriving allergy practice lies in a thorough understanding of the current reimbursement system and allergy coding guidelines. In this article, we shared coding guidelines for allergy testing which will help to receive accurate reimbursement from various payers. Allergy testing is the first step in the immunotherapy process taken by a physician towards tackling the patient’s allergies.

Allergy testing will include the performance, reading, and evaluation of mucous membrane and cutaneous testing, as well as an evaluation of patient history including immunology. It will also include the physical examination which decides on antigens which are to be used, and a complete interpretation of all results. Allergy testing is always covered provided that clinically significant symptoms exist, and that traditional therapies have already failed to achieve results. When allergy testing is necessary, the preferred method to use would be standard skin testing.

Coding Guidelines for Allergy Testing

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 along with the physician taking a history including immunologic history, performing the physical examination, deciding on the antigens to be used, and interpreting results.

Allergy testing cannot be performed on the same day as allergy immunotherapy i.e., the two different billing codes should not be reported together. Although the diagnostic test may not be performed by the physician, the results have to be reported and interpreted by a physician.

Evaluation and management codes reported with allergy testing is appropriate only if a significant, separately identifiable E/M service is performed. 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 must be in the medical record.

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.

Non-Covered Services

  • Sublingual intracutaneous and subcutaneous provocative and neutralization testing and neutralization therapy for food allergies are excluded from coverage because available evidence does not show that these tests and therapies are effective.
  • Challenge ingestion food testing has not been proven to be effective in the diagnosis of rheumatoid arthritis, depression, or respiratory disorders. Accordingly, its use in the diagnosis of these conditions is not reasonable and necessary and no program payment is made for this procedure when it is so used.
  • Cytotoxic leukocyte tests for food allergies are excluded from the coverage because available evidence does not show that these tests are safe and effective.

There is no denying that while you provide care to your patients, you also need to focus on the patient care rather than coding and administrative aspect of your practice. Unfortunately, most medical schools and colleges provide little to no training on managing these functions. However, you can outsource your allergy and immunology services billing to Medisys Data Solutions to accurate coding. To know more about our billing and coding services, contact us at info@medisysdata.com / 302-261-9187

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