Otolaryngology Coding Alert

Despite CPT's revision of 95027, intradermal dilutional testing (IDT), commonly called skin end point titration (SET) testing, remains a sticky matter. But some expert answers on what's new, current guidelines, and coverage should clear your head.

Knowing what these tests are is crucial to understanding how to report them. Otolaryngologists use intracutaneous, sequential and incremental tests to determine the safe starting dose for immunotherapy. IDT allows the physician to determine the lowest dilution that will produce a positive skin reaction.

To identify the low point, the physician conducts repeated tests with different dilutions of the treatment allergen or allergen mixture. The first test contains a weak dilution, followed by a second test that is stronger, says Michelle Lutke, administrator for Greenley Oaks ENT in Sonora, Calif. The doctor increases the strength of all subsequent tests by the given factor, such as 10, until he identifies the "end point" the point at which the negative result becomes positive. "Generally, it takes three tests (dilutions) per allergen to determine the endpoint," according to HGS Administrators (HGSA), Pennsylvania's Medicare Part B carrier.

The IDT concept has been around for a while without any major changes. But CPT recently revised the procedural code used to report the testing.

Before 2003, 95027 referred to "skin end point titration" only. With CPT 2003, the definition expanded to "intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, specify number of tests." To eliminate physician and payer confusion regarding coding requirements and coverage of SET, the AMA changed the code to more properly describe the technique as IDT. Although the new definition changed the wording considerably, the meaning remains the same.

The new definition clarifies one important aspect. You must now specify the number of tests. "Before the definition change, insurance companies would rarely recognize the number of tests without a battle," Lutke says. The wording change more accurately reflects the way offices perform IDT.

Although CPT now requires you to report the number of tests, the definition does not specify what you should base the quantity on.

Without further guidance from CPT, you may wonder whether dilutions, pricks, scratches, injections or allergens unlock the magic number of SETtests to report. But the number of tests refers to the sticks used, according to the American Association of Otolaryngologic Allergy (AAOA).

"Each stick is a separate test that the physician reads and measures for reaction," Lutke says. Therefore, you should bill for each test/stick within each antigen.

To reflect the quantity of tests that the otolaryn-gologist performs, record the number of sticks in the unit box. Do not allow the other mathematical items, such as number of allergens, to cloud your coding.

Consider a patient who requires three tests of increasing strength to determine his end point for 14 allergens, including dog fennel, pine, hickory and Bermuda grass. You should report 95027 x 42 units. Each unit represents one stick or dilutional test per antigen. You can ignore the number of allergens tested.

Code 95027 requires this type of incremental dilutional testing. If the physician performs only one stick or test per allergen, the AAOA considers it straight intradermal testing. In this case, you should bill 95024 (Intracutaneous [intradermal] tests with allergenic extracts, immediate type reaction, specify number of tests) with one stick per antigen, rather than 95027.

Notice that the allergens in the previous example are weeds, trees or grass: organisms that produce airborne pollens. CPT stipulates that 95027 describes testing of airborne allergen(s). These include all the environmental allergens, such as grass, weeds, dust, animals, molds and trees, Lutke says. "Code 95027 is not for food allergies," she stresses. When the otolaryngologist performs IDTof airborne allergens, such as spring tree and grass allergens and fall weed pollens, 95027 is appropriate.

For IDT of other allergens, such as stinging insect venom, use 95015 (Intracutaneous [intradermal] tests, sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, specify number of tests), which does not specify airborne allergens. The code contains more relative value units (0.54) than its "airborne" counterpart 95027, which has 0.16 RVUs.

Some carriers may limit coverage of 95027 to specific allergens. For instance, Cahaba GBA, the Part B Medicare carrier for Georgia, lists accepted airborne allergens that are usually encountered in Georgia. The carrier deems 24 trees, 17 grasses and 22 weeds acceptable for 95027. Consequently, check with the payer for coverage restrictions.

Now that you know how to report 95027 and for what, carrier coverage becomes the issue. Reimbursement for IDT has sometimes been difficult to obtain due to concerns about the procedure's effectiveness. "95027 has not been consistently documented to be a reliable means of determining the optimal dose for therapy," states Regence Blue Cross Blue Shield of Utah, Utah's Medicare Part B carrier. Other states also exclude 95027 coverage. For instance, Texas Medicare (Trailblazer) doesn't pay for 95027, says Lori Bogan, administrator for ENT Associates of East Texas in Tyler.

On the other hand, Lutke has found that payer recognition has been much easier since the code's revision. "Prior to the wording change, we had a lot of trouble with payers recognizing and processing the number of tests," she recalls. "But now, we have had no problems with any insurers not paying."

Most Medicare and private carriers allow IDT if the claim meets three criteria. First, the documentation must identify the test's medical necessity. Next, make sure the carrier permits 95027 for the allergen tested. Finally, you must link the procedural code with an accepted diagnosis. Because of coverage limits, you should obtain an advance beneficiary notice from Medicare patients and append modifier -GA (Waiver of liability statement on file) to 95027.

You should also have the patient sign a waiver if your physician conducts IDT on noncovered patients, Bogan says. Inform the patient that his or her insurer does not provide coverage for the procedure. Consequently, he or she is responsible for the cost.