Otolaryngology Coding Alert

Question: The payer denied our claim for CPT 95117 and 95024 on the basis of CCI edits, but I can't find any documentation on the edits. The American Academy of Otolaryngic Allergy (AAOA) requires that once a patient is skin tested (95024) when they return to the office for their first allergy injection (95117), the nurse must administer a "vial test" to ensure the serum is not too strong. What did we do wrong?

Nevada Subscriber

Answer: You are right. CPT®s 95117 (Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections) and 95024 (Intracutaneous [intradermal] tests with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests) are not bundled. You are performing 95024 on the same day as the initial injections as the proper protocol set forth by the AAOA, but the payers do not necessarily agree with this correct safety process to make sure that the patient will respond appropriately to the antigens.

To counter the denial, it's best you write an appeal and show them the current CCI edits for 95117 and 95024. Also include the AAOA protocol in the denial, and stress that this is being done for patient safety per the AAOA guidelines. However, if you do not want to be continually writing denials, you may set up a meeting with your physician and each of your payer's medical directors, and provide them with the guidelines set forth by the AAOA. Show them that this billing is not unbundling, abuse or inappropriate procedures, rather, it is proper protocol for the safety for the patients. It is better to get the payers' medical directors to change policy so that you are not appealing every initial injection encounter.