AAPC - Back to school
Results 1 to 2 of 2

Thread: 95004 Documentation Requirements

  1. #1

    Default 95004 Documentation Requirements

    AAPC: Back to School
    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?


  2. #2
    Join Date
    Apr 2007


    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.
    Eileen Blankenship, CPC
    Remote Coder

Similar Threads

  1. documentation requirements
    By chadandleanne@windstream.net in forum Emergency Department
    Replies: 0
    Last Post: 02-27-2014, 11:28 AM
  2. Documentation requirements
    By mcohen in forum OB/GYN
    Replies: 0
    Last Post: 06-04-2013, 10:24 AM
  3. E/M Documentation Requirements
    By kristinab in forum E/M
    Replies: 1
    Last Post: 05-19-2011, 07:28 AM
  4. Documentation Requirements
    By rizeninme in forum Compliance General Discussion
    Replies: 1
    Last Post: 12-30-2010, 03:58 PM
  5. Documentation requirements
    By TY0411 in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 11-18-2010, 06:28 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.