Billing and Coding: Allergy Testing

Title XVIII of the Social Security Act, Section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, Section 1862 (a) (1) (A) allows coverage and payment of those items or services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a) (1) (D) excludes investigational or experimental from Medicare coverage.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section excludes routine physical examinations.

42 CFR, Section 410.20 – Physicians’ Services.

42 CFR Section, 410.32 tests not ordered by the physician or other qualified non-physician provider who is treating the patient are not reasonable and necessary. (See 42 CFR 411.15(k)(1).

42 CFR, Section 410.32(b) diagnostic tests must be furnished under the appropriate level of supervision by a physician. Services furnished without the required level of supervision are not reasonable and necessary.

CMS Pub 100-02 Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Sections
20.2 – Physician Expense for Allergy Treatment,
80.1 – Clinical Laboratory Services, and
80.6 – Requirements for Ordering and Following Orders for Diagnostic Tests.

CMS Pub 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1 – Coverage Determinations, Part 2, Sections
110.9 – Antigens Prepared for Sublingual Administration
110.11 – Food Allergy Testing and Treatment
110.12 – Challenge Ingestion Food Testing
110.13 – Cytotoxic Food Tests.

CMS Pub 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1 – Coverage Determinations, Part 4, Section 230.10 – Incontinence Control Devices.

CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners, Section
200 - Allergy Testing and Immunotherapy.
Chapter 16 – Laboratory Services, Section
40.7 – Billing for Noncovered Clinical Laboratory Tests.

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD Allergy Testing L36402.

Coding Information

Billing Guidelines
Evaluation and management codes reported with allergy testing is appropriate only if a significant, separately identifiable E/M service is performed. When appropriate, use modifier -25 with the E/M code to indicate it as a separately identifiable service. If E/ M services are reported, medical documentation of the separately identifiable service must be in the medical record. (CPT guidelines)

Allergy testing is not performed on the same day as allergy immunotherapy in standard medical practice. These codes should, therefore, not be reported together. Additionally, the testing becomes an integral part to rapid desensitization kits (CPT code 95180) and would therefore not be reported separately.

The MPFSDB fee amounts for allergy testing services billed under codes 95004-95078 are established for single tests. Therefore, the number of tests must be shown on the claim. (CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners, Section 200 – Allergy Testing and Immunotherapy, Rev.2997, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01-2012-ASC X12, Implementation: 08-25-2014 – ASC X12; Upon Implementation of ICD-10).

EXAMPLE

If a physician performs 25 percutaneous tests (scratch, puncture, or prick) with allergenic extract, the physician must bill code 95004, 95017 or 95018 and specify 25 in the units field of Form CMS-1500 (paper claims or electronic format). To compute payment, the Medicare contractor multiplies the payment for one test (i.e., the payment listed in the fee schedule) by the quantity listed in the unit’s field.

Part B providers indicate the actual number of tests (one for each antigen) in Box 24G of the 1500 claim form. (CMS Pub 100-04 Medicare Claim Processing Manual, Chapter 26 – Completing and Processing Form CMS-1500 Data Set, Section 10.4 – Provider of Service or Supplier Information, Rev. 3881, Issued: 10-13-17, Item 24G). On EMC claims enter the number in the service field.

Interpretation of CPT codes: 95004, 95017, 95018, 95024, 95027, 95028, 95044, 95052, and 95065 requires the number of tests which were performed. Enter 1 unit for each test performed. For example, if 18 scratch tests are done, code 95004, 95017 or 95018 with 18 like services. If 36 are done, code 95004, 95017 or 95018 with 36 like services.

When photo patch tests (e.g. CPT code 95052) are performed (same antigen/same session) with patch or application tests, only the photo patch testing should be reported. Additionally, if photo testing is performed including application or patch testing, the code for photo patch testing (CPT code 95052) is to be reported, not CPT code 95044 (patch or application tests) and CPT code 95056 (photo tests).

Non-covered services include, but are not limited to, the following services:

a. Sublingual Intracutaneous and subcutaneous Provocative and Neutralization Testing: Effective October 31, l988, sublingual intracutaneous and subcutaneous provocative and neutralization testing and neutralization therapy for food allergies are excluded from Medicare coverage because available evidence does not show that these tests and therapies are effective. (CMS Pub 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2 Section 110.11 – Food Allergy Testing and Treatment (Rev. 1, 10-03-03).
b. Challenge Ingestion Food Testing: Challenge ingestion food testing has not been proven to be effective in the diagnosis of rheumatoid arthritis, depression, or respiratory disorders. Accordingly, its use in the diagnosis of these conditions is not reasonable and necessary within the meaning of §1862(a)(1) of the Act, and no program payment is made for this procedure when it is so used. (CMS Pub 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2 Section 110.12 –Challenge Ingestion Food Testing (Rev. 1, 10-03-03).
c. Cytotoxic Food Tests: Prior to August 5, l985, Medicare covered cytotoxic food tests as an adjunct to in vivo clinical allergy tests in complex food allergy problems. Effective August 5, l985, cytotoxic leukocyte tests for food allergies are excluded from Medicare coverage because available evidence does not show that these tests are safe and effective. (CMS Pub 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2 Section 110.13 –Cytotoxic Food Tests Rev. 1, 10-03-03).

Allergy testing is covered when clinically significant symptoms exist, and conservative therapy has failed. Allergy testing includes the performance, evaluation, and reading of cutaneous and mucous membrane testing, along with the physician taking a history including immunologic history, performing the physical examination, deciding on the antigens to be used, and interpreting results.

Counseling and prescribing treatment should be reported using a visit.
Do not report Evaluation and Management (E/M) services for test interpretation and report.

Standard skin testing is the preferred method when allergy testing is necessary. Each test should be billed as one unit of service per procedure code, not to exceed two strengths per each unique antigen. The number of antigens should be individualized for each patient based on history and environmental exposure.

A visit to an allergist, which yields a diagnosis of specific allergy sensitivity but does not include immunotherapy, should be coded according to the level of care rendered.

CPT procedure code 95060 is payable in place of service that include office, outpatient hospital (off-campus/on-campus), inpatient hospital, and emergency room – hospital settings.

Hospital Inpatient Claims:
Effective January 1, 2006, CMS is differentiating single allergy tests (“per test”) from multiple allergy tests (“per visit”) by assigning these services to two different APCs. CMS is assigning single allergy tests to newly established APC 0381 and maintaining multiple allergy tests in APC 0370.

Hospitals should report charges for the CPT codes that describe single allergy tests (or where CPT instructions direct providers to specify the number of tests) to reflect charges per test rather than per visit and bill the appropriate number of units of these CPT codes to describe all of the tests provided.

Coding Guidelines
Per the CMS Pub National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 11- Medicine Evaluation and Management Services, CPT codes 90000-99999, K. Allergy Testing and Immunotherapy.

If percutaneous or intracutaneous (intradermal) single test (CPT codes 95004 or 95024) and "sequential and incremental" tests (CPT codes, 95017, 95018, or 95027) are performed on the same date of service, both the "sequential and incremental" test and single test codes may be reported if the tests are for different allergens or different dilutions of the same allergen. The unit of service to report is the number of separate tests. A single test and a “sequential and incremental” test for the same dilution of an allergen should not be reported separately on the same date of service. For example, if the single test for an antigen is positive and the physician proceeds to “sequential and incremental” tests with three additional different dilutions of the same antigen, the physician may report one unit of service for the single test code and three units of service for the “sequential and incremental” test code.

Photo patch tests (CPT code 95052) consist of applying a patch(s) containing allergenic substance(s) (same antigen/same session) to the skin and exposing the skin to light. Physicians should not unbundle this service by reporting both CPT code 95044 (patch or application tests) plus CPT code 95056 (photo tests) rather than CPT code 95052.
Evaluation and management (E/M) codes reported with allergy testing or allergy immunotherapy are appropriate only if a significant, separately identifiable service is performed. If E/M services are reported, modifier 25 should be utilized.

In general, allergy testing is not performed on the same day as allergy immunotherapy in standard medical practice. Allergy testing is performed prior to immunotherapy to determine the offending allergens. CPT codes for allergy testing and immunotherapy are generally not reported on the same date of service unless the physician provides allergy immunotherapy and testing for additional allergens on the same day. Physicians should not report allergy testing CPT codes for allergen potency (safety) testing prior to administration of immunotherapy. Confirmation of the appropriate potency of an allergen vial for immunotherapy is an inherent component of immunotherapy. Additionally, allergy testing is an integral component of rapid desensitization kits (CPT code 95180) and is not separately reportable.

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.