Requirements for Reporting Allergy Services Are Nothing to Sneeze At
Make sure your practice is billing testing and immunotherapy preparation and provision correctly.
Allergy services are on the radar of third-party payer investigation units because they have found that many practices code and bill these services wrong. Similarly, many practices fail to follow the Medicare Part B rules for billing the preparation of the allergy immunotherapy serum. Let’s review the requirements for correct reporting of allergy testing, immunotherapy serum prep, and provision of immunotherapy to patients.
Know Supervision Requirements
The first step in the allergy immunotherapy process is allergy testing. Typically, this is performed by medical assistants, nurses, nurse allergists (specialty certification in nursing), and other non-physician providers. You may think these ancillary staff and non-physician providers are working and billing under the incident-to rules, but their services actually fall under the diagnostic services supervision rules, which require the practice to provide them with either “general,” “direct,” or “personal” supervision. Although these levels of supervision are the same as described in incident-to services, a different set of rules apply to diagnostic services. Each diagnostic CPT® code is assigned a supervision level requirement in the Medicare Physician Fee Schedule (MPFS) database depending on the perceived risk of the procedure.
General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required. Under general supervision, the training of the non-physician personnel who perform the diagnostic procedure and the maintenance of the necessary equipment and supplies is the continuing responsibility of the physician.
Direct supervision means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not have to be present in the room where the procedure or service is performed. Direct supervision guidelines for diagnostic testing and incident-to services are the same, but not all diagnostic procedures call for direct supervision.
Personal supervision means the physician must be in the room during the performance of the procedure. This is required for diagnostic procedures that pose the highest risk to the patient.
The MPFS database carries a “1” in the Diagnostic Supervision field if the code only needs general supervision, a “2” if the code requires direct supervision, and a “3” if the code requires personal supervision. If the field carries a “9,” the supervision concept does not apply.
Common allergy testing codes that require direct supervision are:
95004 Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests
95024 Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests
95027 Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report by a physician, specify number of tests
95028 Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify number of tests
95044 Patch or application test(s) (specify number of tests)
95052 Photo patch test(s) (specify number of tests)
95056 Photo tests
High-risk codes requiring personal supervision are:
95060 Ophthalmic mucous membrane tests
95070 Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with histamine, methacholine, or similar compounds
95071 with antigens or gases, specify
The concept of diagnostic testing supervision does not exist, as reflected by a “9” in this field in the MPFS, because neither the provision of the allergy serum nor the allergy shots are diagnostic. Instead, these services fall under the rules of incident-to services and, therefore, require direct supervision if performed by someone other than the physician.
Identify the Type of Skin Testing
Allergy skin testing codes are divided into environmental, venoms, and food (there are other codes for testing other substances, but the bulk of the codes fall into these three broad categories). Some codes, such as 95004, do not differentiate between the type of allergen that is tested.
There are three types of skin testing: prick or scratch testing (most common), incutaneous testing, and sequential and incremental testing.
- Prick or scratch testing “pricks” or “scratches” the surface of the skin to see if there is a reaction to the allergen antigen.
- Incutaneous testing involves a syringe that injects a small amount of the allergen antigen into the skin.
- Sequential and incremental (often referred to as “SET testing” (skin endpoint titration testing)) employs syringes. The testing may involve four or five dilutions, increasing the concentration of the antigen with each dilution, challenging the patient to react to the allergen.
The most common form of allergy testing, often called a “scratch test,” is reflected by CPT® code 95004. The units for this test are counted by the number of allergens tested. If five different allergens are tested, which involves pricking the patient with five different substances and reading the reactions, the code is reported with five units.
Codes 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 and 95018 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests involve any combination of percutaneous (scratch, puncture, prick), intracutaneous (intradermal), sequential and incremental testing. Both tests look for immediate-type reactions and include the test interpretation and report.
Counting the units for 95017 and 95018 is more complicated than with 95004. For these tests, the number of scratch, puncture, or prick tests and incutaneous tests are counted per allergen, as with 95004 and 95024; but then you add the number of dilutions, or the number of patient sticks performed during the sequential and incremental testing.
Example 1: A patient is given four increments of five antigens during the sequential and incremental portion of the testing, for 20 units (4 x 5). This is added to the number of antigens that were prick tested and incutaneous tested (for example, another five antigens). The number of units billed is then 25 (five for the prick testing plus 20 for the sequential and incremental testing. The selection of 95017 versus 95018 is determined by what was tested, venoms (95017) or drugs/biologicals (95018).
Code 95024 represents the second type of skin testing described above, where the skin is injected with allergen antigen to see if a reaction can be provoked. As with prick tests (95004), the units counted for 95024 equal the number of allergen antigens tested.
Code 95027 describes sequential and incremental (SET testing) and is used for environmental allergies. As with 95017 and 95018, the sequential and incremental testing does not count just the number of allergen antigens tested, but also the number of times the patient is stuck (each allergen antigen will require the patient to be tested multiple times at increasing dilutions). If 10 allergen antigens are tested at four dilutions, the number of units billed is 40 (10 antigens x 4 dilutions).
The codes and types of testing discussed so far have been for immediate reactions. An “immediate” reaction is considered to occur within 15-20 minutes. Incutaneous testing, described by 95028, differs in that it looks for a delayed reaction 24-72 hours after administration of the antigen(s).
Account for Allergy Immunotherapy Serum Prep
After testing is completed and the provider has determined what the patient is allergic to, a regimen of immunotherapy is formulated. The immunotherapy starts out with highly diluted antigen, which is gradually increased over time. The goal is for the patient to increase their tolerance to what they are allergic to.
It takes a long time for the dilution to be brought to what is considered the “maintenance dose” for the patient. In 2000, Medicare Part B would not pay for dilutant beyond what is needed for the maintenance dose when billed for the immunotherapy serum. This created a lot of confusion and problems in the specialty. Treatment vials are created from undiluted antigen that are then drawn from and put into dilution vials. Each of the dilution vials have sequentially increasing dilutions. Traditionally, payers are billed for the total number of cubic centimeters (cc) of serum that is created from the non-diluted vial.
Example 2: 10 units of maintenance dose can be diluted down to a total of 70 units. Until Medicare published a rule in 2000, all payers would have been charged for 70 units of serum. After Medicare published this rule, for Part B Medicare only, the practice can only charge for the maintenance doses created: 10 units. All other payers may be billed 70 units, but Medicare Part B may be billed only 10 units.
The rule does not apply to Medicare Advantage plans, but applies to all patients with Medicare Part B. This is important for calculating units for 95145-95180. The most commonly used code for the provision of serum is 95165 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses). Overbilling Medicare Part B for the units for this service is “on the radar,” and can get the practice into trouble. Be sure your Medicare Part B units are calculated correctly!
Factor in Administration
of Allergy Immunotherapy
Administering allergy immunotherapy, commonly known as “allergy shots,” can be performed in a variety of ways. Some allergy practices give the patients the serum vials to bring to their primary care physician (PCP) to administer the shots according to the treatment plan. Some providers let the patients self-administer the shots, while other allergists say they consider patient self-administration to be unsafe.
When the provider who makes up the serum is also the administer of the allergy shots, the provider may make up the sequentially diluted serum sets that are specific to the patient and then administer first from the most diluted vial, moving on to the next most diluted vial, and eventually up to the maintenance vial. Although each vial may have been billed based on 1 cc doses, the doses given to the patient may be 0.5 cc doses, which means a vial can last for 20 doses. The payer pays for the serum up front for 95145-95180 (and most often 95165), times the number of units billed. Then, the practice bills one of the two injection codes.
Some antigens do not mix with other antigens and must be diluted in separate vials. The number of vials determines the number of shots the patient receives. The two possible injection codes for administering immunotherapy are:
95115 Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection
95117 2 or more injections
Note that 95117 is not an add-on code: Do not report 95115 with 95117; one or the other is coded, not both.
Some doctors prepare their serum for immunotherapy “off the board.” Using this technique, the technician works with the formula and has a board of all the different antigens. She draws up into the syringe a specific amount of antigen A, a specific amount of antigen B, and a specific amount of dilution per a formula for the patient, and then administers the shot. Although 95120 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; single injection and 95125 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 2 or more injections) (or 95130-95134 for venoms are the codes that most reflect what is done when allergy immunotherapy is performed “off the board,” no payers process claims using these more appropriate codes. As a result, the practice still must bill as if they make up pre-made vials and then administer the shots, using 95145-95180 (most often 95165) and 95115 or 95117.
Finally, there are providers who make up maintenance dose vial sets and then use an “off the board” process, diluting the patient’s full maintenance dose with the appropriate dilutant when preparing the immunotherapy. These services also must be coded using 95145-95180 (95165, most often), plus the shot administration using 95115 or 95117.
Keep Payer Limits in Mind
Many insurance companies limit the number of allergy tests that may be performed at a single session and may set medical necessity requirements for sequential and incremental SET testing. They also may limit the number of units of antigen they allow for 95145-95180 (most often, 95165) at one time. Be sure to review each payer’s guidelines on their website, so your practice knows the limitations and medical necessity requirements. It’s a good idea to log each payer’s information in an Excel spreadsheet to make sure the practice doesn’t perform services that will not be paid.