Injection Coding Issues for Nonphysician Practitioners

Allergists may employ nonphysician practitioners (NPPs), such as registered nurses and nurse allergists, to perform allergy tests on and inject patients. This practice requires an understanding of diagnostic test and "incident to" guidelines that govern how these services should be billed, as well as the level of supervision required. Diagnostic tests differ from other services in that incident to regulations do not apply; however, CMS has guidelines that indicate the level of supervision required for diagnostic tests.

Document the Proper Physician-Supervision Level

CMS lists three levels of physician supervision for diagnostic tests: general, direct and personal.  Note that direct or personal supervision is required for all allergy tests that NPPs perform, due to the possibility of anaphylactic reaction.
 
1. General supervision. The physician is available for consultation but need not be in the office suite.
 
2. Direct supervision. The physician is in the office suite and is readily accessible. CMS memo B-01-28 recently revised the guidelines, with the following tests requiring direct supervision:


95004 percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, specify number of tests


95024 intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, specify number of tests


95027 skin end point titration


95028 intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify number of tests


95044 patch or application test(s) (specify number of tests)


95052 photo patch test(s) (specify number of tests)


95056 photo tests.

Note: Codes 95010 (percutaneous tests [scratch, puncture, prick] sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, specify number of tests) and 95015 (intracutaneous [intradermal] tests, sequential and incremental, with drugs, biologicals, or venoms, immediate type reaction, specify number of tests) were not included in the CMS memo.
 
3. Personal supervision. The physician is in the same room as the NPP and patient. Codes that require personal supervision include:


95060 ophthalmic mucous membrane tests


95070 inhalation bronchial challenge testing (not including necessary pulmonary function tests); with histamine, methacholine, or similar compounds


95071 with antigens or gases, specify


95075 ingestion challenge test (sequential and incremental ingestion of test items, e.g., food, drug or other substance such as metabisulfite)


95078 provocative testing (e.g., Rinkel test).

Local Medicare carriers are expected to apply the guidelines, unless state scope-of-practice laws or regulations further limit the role of NPPs in such duties. Many states permit three categories of NPPs physician assistants, nurse practitioners and clinical nurse specialists to administer tests within their scope of practice. In these states, the supervision requirements listed above do not apply to these NPPs, and only the equivalent of general supervision is required. A [...]

- Published on 2001-12-01