Outpatient Facility Coding Alert

Published on Mon May 26, 2014 PDF

Starting point: Note the number of allergens tested.

The green grass, blossoming trees, and bright sunshine may give picturesque views but unfortunately the pollens in the air during the spring and summer months cause a plethora of allergies. You could have many physicians in your facility, particularly otolaryngologists, performing “scratch tests,” “prick tests,” or “puncture tests” for allergy evaluation.

Understand Code 95004 

For all the documentation reporting these tests, your provider is referring to 95004 (Percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests).  

In these procedures, physician or a 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. 

Base Your Units on Allergens 

For each allergen tested, you should report one unit of 95004. The units are not based on the scratches. Even if the physician performs multiple scratches for one allergen, that allergen counts as one unit of service.  Your claim form reports the total number for allergens tested.

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.

Understand Supervision Requirements for Diagnostic Testing

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. 

Other important points related to supervision of diagnostic testing include:

• Non-physician practitioners (NPPs) (mid-level providers, nurse practitioners, or physician assistants) cannot bill as the supervisor when non credentialed auxiliary personnel are performing allergy testing. The NPP can bill using his or her own NPI for any testing personally performed. 
• You should be allowed 100 percent of the fee schedule if auxiliary personnel (such as a nurse or medical assistant) perform the test under 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.