Wiki Documentation for Allergen Testing 95044

[SUEV]

When a provider does patch testing, what should be documented in the chart? Is "patches applied" for the 1st visit and "negative results" for the final reading enough? Should each allergen and the result be listed individually? The provider is stating she is doing the standard NA tests of 50 antigens but that isn't documented in the chart either. Does anyone know what has to be documented regarding the patch application itself to support 95044?
Thanks,
Sue

 

[CatchTheWind]

For Florida Medicare, the following documentation is required:

A complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient.
The medical necessity for performing the test.
The test methodology used.
The measurement (in mm) of reaction sizes of both wheal and erythema response.
The interpretation of the test results and how the results of the test will be used in the patient?s plan of care.

I think it goes without saying that proper documentation would require basic information such as the number of patches applied and either a list of allergens or what standard group was used. (By the way, the "standard North American" group that our office uses has 80 allergens, not 50.)