# Documentation Requirement for 95044



## shellysk8 (Mar 22, 2017)

I am seeking the documentation requirement for 95044 - Patch testing. Current practice is that the substances tested are documented on the return visit, but charged on the initial visit when they are applied. The initial note typically indicates the number of substances, and perhaps the "panels" i.e. cosmetic series, perfume series. My gut is telling me that ALL substances tested should be documented during the initial visit OR they should not be charged until the return visit. Otherwise, I believe if there was a documented standard, say in a Department Policy, of what substances are included in each panel, and then it was consistently documented for each patient which panels were tested, that would work as well.

Any idea of where I can find the actual documentation requirements? I see all kinds of information on how to bill, the MUE, etc. but can't locate what I need.

Thanks,
Shelly


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## ellzeycoding (Mar 22, 2017)

I couldn't find any LCDs in Wisconsin (or other states) that cover 95044.

Here is one for Palmetto GBA that handles the Carolinas and VA and WV you can use as an example...

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33417

There is some documentation information at the VERY BOTTOM, but not much.

If you are using the standard patch panels that come from one of the manufacturers, you could just document which Panels were applied, vs individual allergens you are testing for.  For example TrueTest has 3 panels.  1.3, 2.3, 3.3.

On to your question...

On the date of application, I would definitely code  the following.


The medical necessity for performing the tests including the patient history and exam that necessitated the need for testing.
WHICH individual patch tests you applied (or perhaps which standardized panels from the manufacturer)
Total quantity of tests applied
Frequency to schedule the patient to come back for readings. (i.e., patient to come back at 24, 48, and 96 hours).


For each readings, I would document


Which tests reactied positively (or abnormally).
Size of reaction (in mm) of both wheal and erythema response


During the final visit, for interpretation

Document the results and interpretation, and the provider's plan of care for further treatment (or additional testing if necessary).





If you didn't document which tests, how would the provider keep track, other than the markings on the test panels itself.

Remember, if you didn't document it, you didn't do it.


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