Wiki 95004 Documentation Requirements

[SUEV]

Hi-Could someone please tell me what type of documentation is needed for the "interpretation and report" part of code 95004? For example, the physician has a grid of the 40 types of testing he did with the result and the only thing he wrote is "Continue with (med) and return PRN". Would this be considered a report and be enough documentation to bill the 95004?

Thanks,
Sue

 

[eblanken]

Your physician might need to be a little more detailed with his report. The detailed description I have for 95004 is as follows:

Percutaneous allergy tests are performed with allergenic extracts that provoke an immediate reaction. The skin is scratched, punctured, or pricked with one or more allergenic extracts and the test sites are then observed and evaluated by a physician to identify any allergic reaction, such as redness and inflammation. The physician interprets the results and provides a written report that specifies the number of allergens tested, the specific allergenic extracts used, and the absence/presence/degree of allergic reaction to each allergen.

Our practice uses EMR and it allows for the nurse to select which allergens the physician has ordered and then she can input each result. The physician will then dictate his interpretation of the results. Prior to EMR the nurse just had a blank form that she filled out. It listed all of the possible allergens to test and the physician would mark his order and then the nurse would fill in the rest of the information. The physician would then just dictate his report to the transcription system. We have had several instances where carriers have denied these services and we were able to provide a detailed report to send with the claim.

Hope this helps.