Otolaryngology Coding Alert

Consider guidelines from LCDs and other key authoritative sources.

Accurate coding and billing for allergy testing and subsequent immunotherapy provisioning and injections requires that you gather guidelines from a wide variety of sources. What makes this task especially difficult is navigating the rules on code combinations when there are no existing National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits to guide the way.

As you’ll see, there’s plenty of coding references and resources to consider for the coding of both allergy testing and follow-up immunotherapy treatment.

Have a look at some of the most fundamental guidelines to streamline your allergy and immunotherapy coding processes.

Refer to LCD, not NCCI Edits … in Some Cases

There are some instances in which its appropriate to code for both single and sequential/incremental percutaneous or intracutaneous testing. However, you’ve got to be especially careful since no NCCI PTP edits exist between the following sets of single and sequential/incremental testing codes:

Single Testing:

• 95004 (Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests)
• 95024 (Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests)

Sequential/Incremental Testing:

• 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)
• 95018 (…with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests)
• 95027 (Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report, specify number of tests)

When performed on the same date of service (DOS), the Centers for Medicare & Medicaid Services (CMS) lays out some clear guidelines in Local Coverage Determination (LCD) L34597. Specifically, CMS states that you may report single and sequential/incremental testing codes if and when “the tests are for different allergens or different dilutions of the same allergen.” This means that testing on the same dilution of an allergen on the same DOS is not eligible for separate reporting.

You should also be aware of the maximum number of units a provider can bill on a given DOS. Consider medically unlikely edits (MUEs) for some of the following allergy testing codes:

• 95004 — 80
• 95017 — 27
• 95018 — 19
• 95024 — 40
• 95027 — 90
• 95028 — 30
• 95044 — 80

Follow Some Key Rules on Antigen Reporting

Your allergy immunotherapy coding will be dependent on a few important variables. Your documentation needs to fully support the provision (preparation) of the antigen and/or the injection in order to code compliantly. When the documentation supports an allergy injection, but does not include documentation of the provision of the antigen, you will report one of the following two codes, depending on single or multiple injections:

• 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection)
• 95117 (… 2 or more injections)

You’ll report codes 95115 and 95117 during clinical encounters that involve pre-mixed vials of allergen immunotherapy. These codes should be designated for practices that receive provisioned vials from a vendor, and subsequently perform the injection component of the service. On the other hand, for provisioning of the antigen without injection, you’ll report code range 95144-95170.

For instance, if your practice performs the preparation and provision of antigens for three single stinging insect venoms, you’d report code 95147 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); 3 single stinging insect venoms). The code most frequently used for preparation of allergen immunotherapy is 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)).

Payer’s note: If the provider performs the preparation, provision, and injection of the antigen for a Medicare patient, you will report 95165 and 95115/95117, depending on the number of injections. According to L34597, you should not combine the provision/preparation and injection of allergens into a complete code from code range 95120-95134 for Medicare Part B patients:

“Always use the component codes (95115, 95117, 95144-95170) when reporting allergy immunotherapy services to Medicare. Report the injection only codes (95115 and 95117) and/or the codes representing antigens and their preparation (95144-95170). Do not use the complete service codes (95120-95134)!”

CPT^® Assistant (February 2005; Volume 15: Issue 2) further explains that “these codes are used infrequently and are recommended in those cases only where the payer specifically requires them.” Check commercial payer policies to determine if coding for combined services using the complete service code set is appropriate.

CMS note: “Medicare does not pay for diluent when calculating the units for either 95147 or the code most often used, 95165,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey. “Instead, you should only bill for the undiluted maintenance dose. Medicare limits the immunotherapy to 30 units [MUEs] billed at any one time,” explains Cobuzzi.

Non-Medicare: Check your non-Medicare payer websites for their limitations on testing and the units of immunotherapy that they will allow to be billed at any one time. Each payer has its own limitations.

Coder’s note: In the instance that the dose varies depending on a patient reaction, you should not make a change in the number of doses the physician bills. CMS elaborates that this applies to venom and non-venom antigen coding. This means that the billing of the service will not change regardless of whether the patient receives greater or fewer doses than originally planned.