Pulmonology Coding Alert

Question: Are pulmonologists allowed to bill for allergy testing using 95004? We received a denial from Aetna saying that provider specialty may not bill this service. Other payers have reimbursed us for allergy testing performed by pulmonologists, so we’re confused.

Codify Subscriber

Answer: Assuming your state requirements allow for it, there are no general restrictions that bar pulmonologists from reporting 95004 (Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests). But Aetna may require you to get prior authorization for this service, and if you didn’t get that, it’s possible that this prompted your denial.

It’s also possible that you either reported a non-payable diagnosis code, or you billed a diagnosis code that is considered experimental or not medically necessary. Furthermore, since Aetna identifies specific test selection criteria, you may have to provide evidence that the patient has met these treatment criteria before payment is issued. Your best bet is to call Aetna and ask for specifics about your denial. If the representatives say that pulmonologists are not able to report this code, ask them to send you the policy in writing that bars your specialty from billing for allergy testing.