Pediatric Coding Alert

Check your answers to these common allergy questions to keep claims on track.

Every coding professional knows attention to detail is paramount for accurate coding and billing, and this is especially true when reporting allergy testing and subsequent immunotherapy provisioning and injections.

The wide range of allergy tests and treatments available can lead to miscoding and confusion, but help is on the way. Let the answers to these FAQs boost your coding confidence.

What Aspects of Allergy Testing Impact Code Selection?

The allergy testing section of CPT^® (95004-95071) offers a variety of options for reporting these services. When your physician tests a patient for allergies, you will base your code selection on factors such as the type of testing, what they are testing for, and the timing involved for the particular test.

In some cases, the correct code will depend on the nature of the testing. For example, if your provider performs a scratch test, you might end up reporting 95004 (Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests). You might also report 95044 (Patch or application test(s) (specify number of tests)) for patch testing, or 95024 (Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests) for nonsequential intradermal testing.

In other instances, “the correct code will depend not only on the type of test(s) but also on what the physician is testing for as well as the timing of the reaction,” says Barbara Cobuzzi MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare Solutions of Tinton Falls, New Jersey. For example, when your provider uses a scratch test for allergies caused by venoms, such as a bee or a wasp sting, rather than airborne environmental allergenic extracts, you will need to report 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), while you’ll need to reach for 95018 (… with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests)) when your physician tests for allergies to any drugs or biologicals.

What’s Counted To Arrive at Percutaneous Allergy Testing Code Units?

When your physician performs a percutaneous test, also known as a scratch test, prick test, puncture test, or multitest, they apply test solutions that will help assess if the patient is allergic to certain allergens. The provider pricks or scratches the patient’s skin and then administers a tiny drop of a possible allergen to the scratch or puncture to test for an allergic reaction.

Pay attention: The descriptor for 95004 states, “specify number of tests.” This instruction refers to the number of allergens tested, however, not the number of scratches, says Pamela Biffle, CPC, CPC-P, CPC-I, CPCO, owner of PB Healthcare Consulting and Education, Inc., in Austin, Texas. The same principle applies to venom tests, such as code 95017, and drug and biological tests, such as code 95018.

Physicians often want to test several substances at once (often in blocks of eight). During allergy season, these might include ragweed, oak, maple, grass, or other plant pollens.

“Each substance counts as a separate test,” Biffle says. “Total the number of allergens administered and put that number in the ‘units’ field of your claim form.”

For example, testing for ragweed, oak, and grass would translate to reporting 95004 x 3.

Don’t miss: Most of the code descriptors in the allergy testing section of CPT^® say ‘specify number of tests,’ but there are some that do not — those codes are typically reported only once, regardless of the number of tests performed. For example, 95060 (Ophthalmic mucous membrane tests) includes any number of such tests performed at the same encounter.

Is Patch Testing Only Coded Once per Patient?

If the allergist opts to perform a patch, or thin-layer rapid use epicutaneous (T.R.U.E.) test, you’ll submit 95044 for the test. As you do when reporting percutaneous tests, you will have to base the number of units of the code on the number of tests performed (usually one test per allergen). This means you will need to count out the number of patches that your clinician has applied and report the appropriate number of tests in block 24G of the CMS-1500 form, or you will lose out on deserved pay.

So, for instance, if your provider placed a total of 24 patches on the patient’s back, you would have to indicate 24 units on the claim form and provide documentation that your clinician did that number of allergy tests to support your claim. The code descriptor guides correct reporting of the number of units of service in that it says, “specify number of tests.”

Important: It is best to educate your physician and staff so that they are all aware of the need to document the correct information about the number of tests that you will have to claim for. This way, you will neither be reducing the counts and losing on deserved pay, nor be counting higher and risk the chances of denials or overpayment on your claim.

Stacy Chaplain, MD, CPC