Pediatric Coding Alert

4 ways you can tell 95004-95028 apart
 
Assigning the wrong allergy test code could cost you big bucks, but you can improve your 95004-95028 pay if you know the fundamental differences among these diagnostic tests.
 
Relative value units for 95004-95028 vary from a 0.60 high (95010,  ) to a 0.11 low (95004, Percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction, specify number of tests). That means choosing the wrong code will significantly affect your revenue. For instance, selecting 95004 instead of 95010 will cost your practice 0.49 RVUs (more than $18) per antigen. Combine that loss with the usually accepted number of antigens tested - 14 - and you'll lose over $253 on a single claim.
 
To avoid this unintentional revenue loss, coding experts offer four tips for distinguishing among codes in the 95004-95028 family.

1. Know the Test's Type

You should report allergy testing based on whether your pediatrician or nurse administers a percutaneous or an intracutaneous test. When your pediatrician administers the test through the skin, you should report a percutaneous skin test, says Jami Lucas, American Academy of Otolaryngic Allergy (AAOA) executive director in Washington, D.C. These tests include scratch, puncture and skin tests, which CPT Codes defines as 95004 and 95010, she says.
 
If your pediatrician instead injects a substance into the patient's skin, you should report an intracutaneous or intradermal test, Lucas says. Possible tests include 95015 (Intracutaneous [intradermal] tests, sequential and incremental, with drugs, biologicals, or venoms, immediate type reaction, specify number of tests), 95024 (Intracutaneous [intradermal] tests with allergenic extracts, immediate type reaction, specify number of tests), 95027 (Intracutaneous [intradermal] tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, specify number of tests) and 95028 (Intracutaneous [intradermal] tests with allergenic extracts, delayed type reaction, including reading, specify number of tests).

2. Check the Substances Tested

The next factor that you need to consider is whether your pediatrician tests the child for environmental and food allergens rather than biological or insect substances. Codes 95004, 95024 and 95028 all describe testing allergenic extracts, such as weed, grass, mite, animal dander and food, according to CPT Assistant, summer 1991. Watch out: You should also use 95027 for airborne allergens only, which includes all the environmental allergens, but not food allergies, says Michelle Lutke, coding specialist at Greenley Oaks in Sonora, Calif. On the other hand, 95010 and 95015 involve testing the patient for reactions to antibiotics, biologicals, stinging insects and local anesthetic agents.

Consider the following test description: Your pediatrician applies dust, dog dander and molds to skin scratches. In this case, you should report 95004 for percutaneous allergenic extract tests, which all payers cover, Lucas says.

Suppose your pediatrician injects penicillin into a child's skin. For intradermal antibiotic testing, you should report 95015.

3. Verify the Reaction Time

You should also check whether staff administers straight or sequential intradermal testing. In 95010, 95015 and 95027, the pediatrician injects small amounts of suspected allergens intradermally over time. These tests usually take one to three hours. During this interval, your pediatrician observes the injected area for 15-20 minutes. In 95027, your pediatrician gradually administers more concentrated amounts of the antigen to determine the patient's immunotherapy starting point, Lutke says.
 
Most allergy tests involve immediate same-day reactions. When your pediatrician evaluates allergenic extract responses, 24-72 hours after injecting the patient, you should assign 95028 to indicate a test involving a delayed reaction. The code includes the interpretation of the test results 24-72 hours later.
 
4. Determine the Billing Method

You should report all skin tests per antigen except 95027. Even if your pediatrician performs multiple scratches, pricks, punctures or intradermal injections, you should report in the units box how many allergens your pediatrician tested. For instance, your pediatrician tests a child for 10 allergens. You should bill 10 units. Even though your pediatrician may perform six pricks or injections for each test, you should bill only one unit per antigen.
 
The only exception to this rule is with 95027. You should bill this code per dilutional testing. "The pediatrician or technician has to read and measure each stick for reaction," Lutke says. Therefore, you should bill one 95027 unit for each test or stick within each antigen, she says. For instance, if your pediatrician tests a child for 12 allergens and performs three dilutions per substance, you should report 95027 x 36 units.