espressofa99
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I am new to allergy coding and I am trying to understand the documentation guidelines and what is necessary to substantiate the codes billed.
know you are supposed to have an ?order? for allergy testing, but what the practice is documenting, is they are seeing the patient and then sending them down for allergy testing and documenting the need for an allergy consult. Would that suffice?
The LCD (L30471) refers to: Allergen Immunotherapy
1. Include in the record the following information: Medical history, examination, and results of diagnostic testing (including allergy testing) upon which the need for the treatment is based.
Does this imply that a separate exam must be done as well for the immunotherapy or can the notes from the exam that led up to the allergy consult be enough?
Also another LCD (L29056) states: Progress notes that document physician management during the course of the allergic disease, anticipated length of treatment, and explanation of any deviations from normal treatment frequency.
Does this imply that the MD must be writing the progress notes when the patient comes in for immunotherapy? Or since the nurse is the person administering the shot, can she write her progress notes and have the MD sign off on them?
Any guidance or if anyone could tell me where I can go to get this information, would be greatly appreciated.
know you are supposed to have an ?order? for allergy testing, but what the practice is documenting, is they are seeing the patient and then sending them down for allergy testing and documenting the need for an allergy consult. Would that suffice?
The LCD (L30471) refers to: Allergen Immunotherapy
1. Include in the record the following information: Medical history, examination, and results of diagnostic testing (including allergy testing) upon which the need for the treatment is based.
Does this imply that a separate exam must be done as well for the immunotherapy or can the notes from the exam that led up to the allergy consult be enough?
Also another LCD (L29056) states: Progress notes that document physician management during the course of the allergic disease, anticipated length of treatment, and explanation of any deviations from normal treatment frequency.
Does this imply that the MD must be writing the progress notes when the patient comes in for immunotherapy? Or since the nurse is the person administering the shot, can she write her progress notes and have the MD sign off on them?
Any guidance or if anyone could tell me where I can go to get this information, would be greatly appreciated.