Primary Care Coding Alert

Hint: Watch number of allergens tested when counting units of code.

When your FP performs allergy testing, you will need to base your code selection on what your clinician was testing for and what sort of a test he administered. You also need to be aware when you should report an E/M code for the visit.

Background: The allergy testing section of CPT^®, which encompasses codes 95004 through 95071, offers a variety of options for reporting these services. In some cases, the correct code will depend on the nature of the testing. For example, if your clinician performed a scratch test, you might end up reporting CPT^® code 95004, Percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests, but if he did a patch test, you might report CPT^® code 95044, Patch or application test[s] [specify number of tests].

In other instances, the correct code will depend not only on the type of test but also for what the physician was testing. For instance, when your FP uses a scratch test for allergies caused due to venoms, like a bee or a wasp sting, rather than 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 need to reach out for 95018 (… with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests) when your clinician performs allergy testing to any drugs or biologicals.

Myth 1: Count Scratches/ Pricks for Units of Allergy Testing Code

Reality: When your FP performs allergy testing, he will typically perform the testing for many different allergens. For most allergy testing codes, you will have to report the right number of units of the allergy testing code based on number of tests and not on the number of scratches or pricks that your clinician made.

When your clinician performs a percutaneous test, he will apply test solutions that will help assess if the patient is allergic to certain allergens. Your clinician will usually apply these tests to watch reactions to several allergens (often in blocks of eight), and each substance counts as a separate test. Based on the number of substances your clinician is testing for (i.e. the number of tests performed), you will need to report the appropriate number of units for most allergy testing codes, such as 95004. The same principle applies to venom tests, such as code 95017, and drug and biological tests, such as code 95018.

Example: Your FP reviews an 18-year-old boy who complains of severe sneezing, runny nose, difficulty in breathing, skin rashes, and itchiness of the skin. The patient says that he went on a field trip where he accidentally fell on some wild weeds when he received some stings from some unknown insect that he thought was a bee or a wasp.  Your clinician decides to perform allergy testing and tests the patient for four allergens and two insect stings through two separate scratches. You report 95004 x 4 units for the four allergen tests and 95017 x 2 units for the insect sting tests.

“Most of the code descriptors in the allergy testing section of CPT^® say ‘specify number of tests,’” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Some do not, and those are typically reported only once, regardless of the number of tests performed. For example, code 95060 (Ophthalmic mucous membrane tests) includes any number of such tests performed at the same encounter,” Moore says.

Myth 2: Report Patch Tests Only Once for a Patient

Reality: Not true. Again, as in percutaneous tests, you will have to base your reporting of the number of units of 95044 depending on the number of tests done and not report one unit of the code for the patient on one calendar date of service.

When your FP performs a patch (or T.R.U.E.) test, you will have to report the test with 95044. As you do when reporting percutaneous tests, you will have to base the number of units of the code on the number tests done (usually one test per allergen). So, you will need to count out the number of patches that your clinician is applying and report the appropriate number of tests, or you will lose out on deserved pay. You will have to report the number of units in block 24G of the CMS-1500 form.

So, for instance, if your clinician placed a total of 24 patches on the patient’s back, you will have to claim for 24 units on the claim form and provide documentation that your clinician did that many number of allergy tests to support your claim.

“Again, the code descriptor guides correct reporting of the number of units of service in that it says ‘(specify number of tests),’” points out Moore.

Important: It is best to educate your clinician and your staff so that they are also aware of providing the correct information about the number of tests that you will have to claim for so that 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.

Myth 3: Report Additional Units of 95044 For Follow-up Visits

Reality: This is not true. You will report the appropriate number of units of 95044 for the first visit and do not report additional units of the code for follow-up visits.

The patch test is not an “immediate type reaction” test like the percutaneous test. Unlike percutaneous tests, your clinician will only administer the patches containing samples of allergens to the patient’s back in the first visit and will read the results of the tests in a follow-up visit. So, the patient is asked to return in 48 hours (and, in some cases, once more after 72 and/or 96 hours) so that your FP can see the reaction to the allergens.

During the first visit, you will have to report the number of units of 95044 depending on the number of allergens your clinician is testing for using the patch test. You can also code for E/M services your FP provides to the patient, if the documentation supports that the FP provided the necessary key components of an E/M service over and above the testing.

“If you report an E/M code in addition to 95044, you may also need to append modifier 25 to the E/M code to indicate that it was significant and separately identifiable from the allergy testing,” says Moore. “Correct Coding Initiative edits otherwise bundle E/M codes into 95044.”

When your clinician sees the patient for a follow-up visit to check the results of the patch test, you cannot report this visit with additional units of 95044. Reading the results at a subsequent visit is included in the initial billing of 95044 and not separately reportable. Instead, you will have to report an appropriate E/M code for the visit. In many a case, your clinician would have been able to pinpoint the allergen that is causing the allergic reactions in the patient based on the results of the tests. In such situations, your clinician might spend time with the patient discussing the diagnosis and counseling him on treatment options. If your physician spends more than half of the total length of the visit counseling the patient, you can use time to determine the level of E/M code to report.

Don’t miss: If a nurse reads the patch tests and the physician does not otherwise engage with the patient, consider reporting 99211, as long as your physician is on-site when the staff member reads the results.