Otolaryngology Coding Alert

Are you confused about coding for intradermal dilutional testing? Your payers are, too, so you're going to have to arm yourself with the facts if you want to get the payment you deserve for this increasingly popular diagnostic tool.

Getting payment for 95027 (Intracutaneous [intradermal] tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, specify number of tests) "is the most difficult problem we face with allergy testing," says Connie Simonic-Oot, a coding and billing specialist with Head and Neck Surgery Associates PC in Indianapolis.

Practices commonly see denials for intradermal dilutional testing -- also known as skin end-point titration or SET -- for a number of reasons. Some payers call SET an "unproven methodology," while others can't agree on the best diagnosis codes to link to 95027. Sometimes payers even insist that the dilutional tests should be bundled with one-time intradermal tests.

"Both Medicare and Blue Cross here in Texas won't pay for it," says Lori Bogan, administrator for ENT Associates of East Texas in Tyler. She's not alone. United and Tricare/CHAMPUS are two more payers that don't like 95027.

When dealing with payers that have established policies labeling 95027 as experimental, there's not a whole lot you can do except have the patient sign a waiver. An airtight waiver is important because the many separate tests of different dilutions can quickly become very expensive. "We make patients sign a waiver saying that they'll be liable for the cost, but we only charge them about half the cost because it can be so expensive," Bogan says.

Remember that whatever waivers you use or whatever you decide to charge, "you absolutely have to treat everybody the same" if you want to stay out of trouble, says Teresa Thompson, CPC, an ENT coding specialist and owner of TM Consulting in Sequim, Wash.

One misconception that you can overcome is the idea that 95027 can't appear on the same claim as 95004 (Percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction, specify number of tests) or 95024 (Intracutaneous [intradermal] tests with allergenic extracts, immediate type reaction, specify number of tests). Many payers are too quick to reject such claims assuming that the two codes should be bundled.

A savvy subscriber in Simonic-Oot's office was able to overcome such a denial by quoting The Centers for Medicare & Medicaid Services'Correct Coding Manual to the reluctant payer. According to the manual, "If percutaneous or intracutaneous (intradermal) 'sequential and incremental'injections ... and single injection (CPT codes 95004 or 95024) tests are performed on the same date of service, both the 'sequential and incremental' injection and single injection test codes may be reported if the tests are for different allergens or different dilutions of the same allergen."

Payers may balk when they see both 95024 and 95027 with the same allergens on the claim -- but what they may be forgetting is that as long as the physician is not repeating the same dilution of the same allergen, he can bill for both. For instance, "If the single injection test for an antigen is positive and the provider proceeds to 'sequential and incremental'injection tests with three additional different dilutions of the same antigen, the provider may report one unit of service for the single injection test code and three units of service for the 'sequential and incremental'test code," according to the manual.