Oncology & Hematology Coding Alert

Question: How do we report when our physician tests for multiple allergens? Do we report a single unit of 95004 per encounter? What are the physician supervision requirements for 95004?

Ohio Subscriber

Answer: For each allergen tested, you should report one unit of 95004 (Percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests). 

Remember: The units reported are not based on the scratches. Even if the physician performs multiple scratches for one allergen, you count that allergen as one unit of service. Your claim form reports the total number for allergens tested.

Follow this example: A physician performs a test on a patient, who complains of skin rashes, for reactions to ragweed, oak, maple, and dust mites. You should report 95004 x 4 units for the tests performed.

Understand supervision requirements: Medicare requires direct physician supervision of allergy testing services, including those that qualify for 95004. You have to report all allergy diagnostic skin testing services using the name and NPI for the on-site supervising physician at the time of service.  It is possible in medical group practices with multiple physicians. The supervising physician may differ from the ordering physician if performed on a different date of service then ordered. 

Other important points related to supervision of diagnostic testing include:

• You should be allowed 100 percent of the fee schedule if auxiliary personnel (such as a nurse or medical assistant) perform the test under direct physician supervision.
• If an NPP performs and bills the test, you’ll receive 85 percent of the allowable payment from Medicare. The current, adjusted non-facility payment for 95004 (based on the national conversion factor of $35.8228) is $6.45 with a total RVU of 0.18.

What is allergy testing? Your physician may be performing “scratch tests,” “prick tests,” or “puncture tests” for allergy evaluation. For all the documentation reporting these tests, your provider is referring to 95004.

In these procedures, physician, nonphysician practitioner or auxiliary personnel (nurse or qualified technician) performs a percutaneous test with allergenic extracts to find out which substances (allergens) trigger an allergic reaction in the patient. Code 95004 applies to allergens such as dust, cat dander, mold, pollen, and dust mites.