Otolaryngology Coding Alert

Counting units, not scratches, is key with 95004.

Springtime pollen is upon us, which means your otolaryngologist could be seeing more patients to test for specific allergies. Refresh your knowledge of reporting one of the most common tests – the scratch test – to file your claims correctly. 

Learn the Code’s Purpose 

If you see documentation of procedures such as “scratch test,” “prick test,” or “puncture test,” your provider is referring to 95004 (Percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests). You might also see reference to the procedure as a “multi-test” for allergies. 

What happens: In a scratch test, the provider applies test solutions of possible allergens to scratches or shallow punctures of the skin. Code 95004 applies to allergens such as dust, cat dander, mold, pollen, and dust mites. 

Note: In previous years, you reported 95010 (Percutaneous tests [scratch, puncture, prick] sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, including test interpretation and report by a physician, specify number of tests) for some of the other allergens, but that code was deleted in January 2013. Instead, you report codes for combination puncture/prick testing such as 95017 (Allergy testing, any combination of percutaneous [scratch, puncture, prick] and intracutaneous [intradermal], sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests) or 95018 (Allergy testing, any combination of percutaneous [scratch, puncture, prick] and intracutaneous [intradermal], sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests).   

Count Your Units Correctly  

You should report one unit of 95004 for each allergen tested – not based on each scratch. Even if the physician performs multiple scratches for one allergen, that allergen counts as one unit of service.  The total number for allergens tested goes in the “units” field of your claim form.

Example: A physician tests a patient for reactions to ragweed, oak, maple, and dust mites. You report 95004 x 4 units. 

Understand Supervision Requirements for Diagnostic Testing

Although the supervision guidelines are similar to incident to rules, the rules actually fall under different rules, the Supervision for Diagnostic Testing when it comes to allergy testing. Medicare requires direct physician supervision of allergy testing services, including those that qualify for 95004. Report any allergy diagnostic skin testing services using the name and NPI for the on-site supervising physician. 

Other important points related to supervision of diagnostic testing include: 

• Non-physician practitioners (NPPs) (mid-level providers, nurse practitioners, or physician assistants) cannot bill as the supervisor when non credentialed auxiliary personnel are performing allergy testing. The NPP can bill using his or her own NPI for any testing personally performed. 
• You should be allowed 100 percent of the fee schedule if auxiliary personnel (such as a nurse or medical assistant) perform the test and bill by the on-site supervising physician. 
• If an NPP performs and bills the test, you’ll receive 85 percent of the allowable payment from Medicare. 

The current, adjusted non-facility payment for 95004 (based on the national conversion factor of $35.8228) is $6.45 with a total RVU of 0.18. 

Check Specifics Before Reporting E/M 

As with any other procedure the otolaryngologist performs, always verify documentation to ensure it meets requirements before you submit an E/M code with 95004. 

Take note: The descriptor for 95004 specifies that the code includes the physician’s test interpretation and report. Because of this, don’t submit an E/M code if the patient only comes to the office to receive test results. 

Tip: Ask your physicians to document the testing interpretation with documentation of the actual test. When you report the test code, you need documentation for both the test and the interpretation. Keeping the notes together makes it easy to see both components during an audit.  

You can report an E/M service during the same encounter as allergy testing or sharing test results, if the situation supports modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). 

For example, if the patient mentions that they have been feeling ear pain radiating down their right jaw during the visit for allergy testing, the physician sees the patient, documents a comprehensive interval history, an expanded problem focused exam and the MDM is documented as low with this new problem. The doctor would code a 99213-25 along with the allergy testing on that day. The diagnosis associated with the E&M will be 383.70 for unspecified ear pain and 381.81 for Dysfunction of Eustachian tube.  The diagnoses for the allergy testing would include the signs and symptoms as well as the definitive diagnoses that lead the otolaryngologist to order the testing.  These can include 478.19 for Other disease of nasal cavity and sinuses (for the patient’s nasal obstruction) and perhaps 478.0 for Hypertrophy of nasal turbinates.