The Complete Allergy Billing Cheat Sheet

The Complete Allergy Billing Cheat Sheet

In standard medical practice, allergy testing cannot be performed on the same day as allergy immunotherapy, and this means that the two different billing codes should not be reported together. The MPFSTB fees for allergy testing services must be billed using codes 95004 through 95078, and these are all established for single tests.

For this reason, the number of tests administered must always be shown on any billing claim. As an example, if a physician performs 25 percutaneous tests involving allergenic extracts, the appropriate billing code would be listed and then 25 would have to be listed in the units field. Thus, the Medicare carrier would multiply the payment for one task times the number of units in order to calculate the total payment reimbursement. This same methodology applies whether the allergy testing is by scratches, punctures, or pricks.

Non-covered services

Allergy testing is always covered provided that clinically significant symptoms exist, and that traditional therapies have already failed to achieve results. Allergy testing will include the performance, reading, and evaluation of mucous membrane and cutaneous testing, as well as an evaluation of patient history including immunology. It will also include the physical examination which decides on antigens which are to be used, and a complete interpretation of all results.

When allergy testing is necessary, the preferred method to use would be standard skin testing, and each of these tests must be billed as one unit of service for each procedure code. This must not exceed two strengths for any given unique antigen. Saline controls and histamines are allowable and these can be billed as two antigens. The total amount of antigens should be specific to each individual patient, based on their history and their exposure to the environment.

Here is a partial listing of those services which are specifically excluded from allergy testing billing:

  • Subcutaneous provocative and sublingual intracutaneous and neutralization testing for food allergies must be excluded from Medicare coverage, since current evidence does not support their effectiveness
  • challenge ingestion food testing has not been shown to be effective for diagnosing depression, respiratory disorders, or rheumatoid arthritis. For this reason, its usage is not considered to be necessary or reasonable, and therefore is not included in the payment program
  • cytotoxic food tests are excluded because current evidence does not support the fact that they are either safe or effective, and must therefore remain outside the payment program.

Hospital inpatient claims

CMS currently differentiates individual allergy tests from multiple allergy tests by assigning the two services to different APCs. CMS assigns single allergy tests to APC 0381, which has been newly established for that purpose, and multiply allergy tests are included under APC 0370. Therefore, hospitals must report charges for the CPT codes describing single allergy tests to reflect charges on an individual test basis rather than per visit, and will be obliged to bill the appropriate number of units with these CPT codes, so that all tests provided can be included on the claim.

Allergy coding guidelines 

Allergy testing should not be performed on the same day as allergy immunotherapy according to standard medical practice. Instead, allergy testing must be executed before immunotherapy, so as to identify the offending allergens. CPT codes for immunotherapy and allergy testing are not reported on the same service date, unless the physician performs both services on that same day. Physicians should not be reporting allergy testing CPT codes for potency testing prior to the carrying out of immunotherapy.

Confirmation of potency of any allergen for immunotherapy is considered to be an inherent component of immunotherapy. Allergy testing is a major component of rapid desensitization kits, and is therefore not to be reported separately. Whenever percutaneous or intracutaneous single tests are performed on the same service date, using CPT codes 95004 or 95024, and CPT codes 95017, 95018, and 95027 respectively, both the sequential test and single test codes can be reported, provided that the tests are for different allergens.

The unit of service which must be reported is the number of separate tests, and a single test for the same dilution of an allergen cannot be reported separately on the same service date. As an example, if a single test for an antigen is positive, and a physician then performs a sequential test with two additional dilutions of the same antigen, the physician would only be able to report one unit of service for a single test code, in addition to the two units of service for sequential and incremental test codes.

When CPT code 95052 is used on photo patch tests, the procedure must consist of an allergenic substance which is applied to a patch, and which is then exposed to normal lighting. This particular type of test must not be unbundled by reporting CPT code 95044 (patch or application test) plus CPT code 95056, which is a photo test. The appropriate test code to use for this kind of testing is 95052. Evaluation and management codes which are reported with allergy immunotherapy or allergy testing can only be used when a separately identifiable service is executed. In such cases, modifier 25 must be utilized.