Drug Hypersensitivity

Transcription

1 Question When performing drug skin testing, we use the code for each skin test (either prick or intradermal) to each drug component. Should we (and if so how) bill for the controls (one prick histamine, one prick saline, and one intradermal saline). The doctor is wondering how to bill, or if it is even possible, for a penicillin test and challenge as well as a follow up for strep. Is diagnosis pointing enough or do we need particular modifiers? We recently did medication testing on a gentleman who experienced problems of diffuse erythema and a drop in blood pressure with concern of anaphylaxis requiring treatment with epinephrine, corticosteroids, and antihistamines. There were 10 different medications of concern administered at the time. We had the gentleman in our office for testing to these different medications with a total of 48 for code Medicare denied stating over MUE limits. Patient was in the office for 3-1/2 hours total for this testing session. Will Medicare override an MUE with further documentation or do you have any other suggestions for this claim for us. I have a question about ASA challenge and ASA desensitization: how to bill. If the doctor wants to challenge aspirin first and then do a desensitization due to results of challenge, can this be billed on same day? Say an oral challenge takes 6 hours, then continues on to a desensitization for 2 more hours and then patient returns next day to continue desensitization. Can I bill oral challenge for the 6 hours and then a desensitization for the 2 hours same day? Our clinic has a few questions about charging an office visit when the patient is in the clinic for skin testing and/or oral challenge. I did find the attached coding for penicillin challenge and I just wanted to verify this information still holds true? Since oral challenge is time based codes, it would be inappropriate to bill for E/M visit unless the challenge is discontinued due to a reaction then the E/M can be billed? It s my understanding the time for the completed portion of the challenge would be billed along with the appropriate level of E/M, however the challenge time does NOT count towards the E/M time? I also found the information below in the AAAAI media library. Skin testing: CPT if an E/M service is charged on the same day as the test, the E/M service must be significant and separately identifiable beyond the definition of the testing code. Patch testing: CPT when the patient returns for the reading and removal of the patch we could then bill an established patient E/M code. Drug Hypersensitivity Answer There is a limit on the number of pricks or intradermals allowed for the CPT The limit is 19. Some payers are currently stating in their policies that the controls are included. Other payers allow the controls. Historically, allergists have charged for the controls. You should be able to bill the and the oral challenge on the same day without any modifiers. Your diagnosis codes should support both. You could appeal with documentation to see if the MAC would override the edit. My other thought is did you bill on different lines with a 59 modifier to indicate different medication testing on the same day?" If the intent is to desensitize the patient to ASA, billing the entire time for desensitization would be appropriate. The information you have found still is correct and the responses to your questions regarding the E/M and challenge are also correct.

2 What is the proper procedure: We give amoxicillin oral at 0.03, 0.06, use time documentation and so on is this considered an oral challenge or a rapid de-sensitization? Patient had skin testing done to evaluate allergy to amoxicillin which was positive. Amoxicillin was required to add to her treatment regimen to treat a chronic bone infection. The doctor did an oral desensitization to amoxicillin. I had a question regarding Pre pen and Pen G testing. Do I bill for the Pen G and Prepen separately from code 95018? I have looked at the ALK site and also found the article from AAAAI Coding for Penicillin Testing, did not see a drug code. Our provider has been approached by a local hospital to do inpatient PCN testing. The patients would not be established patients with our practice but rather patients who are hospitalized for non-allergic reasons that have indicated that they have a Hx or think they have a Hx of PCN allergy. The hospital wants us to determine if the patient truly is allergic to PCN so that they may treat the patient with that classification of antibiotics. I believe that when done in the office we can only bill for the penicillin testing (no E&M code). Since these patients are inpatient, would the doctor also have to do an H&P on a different date than the test? I have found your spreadsheet with coding information. I am aware now how to bill CPT instead of CPT and CPT I still would like to know if we should be billing for the penicillin serum and pre-pens? We are trying to bill for a lidocaine challenge performed using subcutaneous injection. The test was done using IV and spanned a total of 3 hours. This was performed in similar fashion to ingestion challenge testing, CPT codes Do you have any billing suggestions other than to use unlisted CPT code 95199? I am looking to do a subcutaneous injected drug challenge to mepivicaine. There is no oral ingestion component. What CPT code do I use for billing? I billed with ICD-10 code to Medicare for penicillin skin tests but the claim was denied for an incorrect code. What code should I use for penicillin skin test? What is the proper CPT code to use for a 2 hour penicillin oral challenge with observation on a patient who was previously evaluated for penicillin skin testing (history and physical). The patient comes in now for penicillin skin testing. The patient is here for penicillin prick and intradermal skin testing. If the penicillin skin testing is negative by prick and intradermal, the patient is then given amoxicillin 250 mg orally and observed for 2 hours. Could you give me the CPT codes to use for the skin testing and two oral challenge observation? Drug Hypersensitivity What is your intent? Are you finding out if the patient is allergic or do you know they are allergic to penicillin and you are desensitizing? If the intent was to desensitize the patient with the multiple doses, you may use the If the intent was to determine if the patient would have a reaction after ingesting the multiple doses, you would bill an oral challenge. The cost of the penicillin is included in the RVIU value for the For inpatient testing, your physician would have a consultation (either a or a ) for the evaluation of the patient prior to ordering the penicillin testing. If your physician administers the test and is with the patient the entire time, he could charge for the and the If he writes orders and the nursing staff administers the test, your physician would not be able to charge for the testing. The CPT codes for penicillin are for drugs and biologics which includes both percutaneous and intradermal testing codes. If your physician administers multiple doses of penicillin over a period of greater than 60 minutes, you may also charge for the in addition to the skin testing codes. The cost of the penicillin is included in the testing codes. You may use the codes for the injection and the IV code 96365, etc. for the lidocaine challenge. The codes in this section are not only for therapeutic services but also for diagnostic and prophylactic services. "You should use your diagnostic and therapeutic injection code You may use it more than one time." You may want to consider the Status code Z88.0 for penicillin testing or the T code for penicillin. When you perform penicillin challenges you may bill for the percutaneous and intradermal test with the CPT code The units will be for the total number of tests performed. The oral challenge codes are for the first two hours and for each additional hour. You must provide more than one dose to support the oral challenge.

3 Drug Hypersensitivity I assume the patient is not charged an E/M code. I assume the patient is billed only for the penicillin skin testing and? Two hour oral challenge observation? When you use CPT codes & for IV drug challenge, does it mean you are doing The CPT codes 96365, are used for IV diagnostic or challenge. You would use the for the testing by starting an IV in the patient to do the test or that you are using an IV drug for scratch or ID testing for drugs. the Scratch and ID Testing? I have a question about penicillin testing: Do most Allergists have the patient pick up the RX The CPT value includes the cost of the penicillin or other drug into the code. at the pharmacy and bring to the appt. Then, charge CPT for the procedure to do the testing? I am in the process of billing a patient who was seen in our office for anesthesia testing. Her initial visit included 3 pricks (billed as 95017) and 4 ID's (billed as 95024). Could we have billed all 7 using 95018? Her second visit included 8 pricks, 7 ID's and 11 subcutaneous injections. The patient was seen in our office for 6-7 hours. Can we bill this patient as follows? (Office visit) = 26 (prick's/id's/sub q's) = = 2 I know that 95076/95079 can be used for po challenge and for SC or IM drug challenge. Could 96365/96366 be used for an IV drug challenge? (ex: inpatient needs IV antibiotic and due to history, drug challenge is needed?) I have a claim where the Dr. did a skin test for Tdap on a patient. The Dr. would like me to bill for the vaccine used. However less then 1 cc was used for the test. I did some research and I know that the JW modifier is not allowed with the Can I bill for the vaccine or is it included in the 95018? Earlier this year we did 2 Drug Challenges on a Tricare patient and they are denying the claims stating the code is not specific enough. They have the authorizations on file using this code but they still want another code. My provider completed an Azithromycin challenge and used the code Z88.1 then did a Penicillin Challenge and used the code Z88.1, I was going to submit the code Z88.0 for the Penicillin Challenge but I am not sure about the Azithromycin. I have tried to look for the Tricare Medical policy and have not had any luck. Would you have any recommendations for how to proceed in this case either different codes or steps went the claim is resubmitted or where to find the policy? We saw a patient today and we did anesthetic testing. After the testing we have determined he is not allergic. What would you recommend we use as a diagnosis code, since he s no longer allergic? For this patient we also did a pulmonary function test to confirm that he does not have any issues w/ his breathing, before and after the test. What diagnosis do you recommend we use? No history of breathing issues. On your initial visit you will bill all of the tests - pricks and ID's under the The includes percutaneous and intradermal tests. On your second visit, I am not sure why you are coding for a since it would be an established patient encounter. You would code the for the ID tests and the subcutaneous injections would be codes with the x11 for the diagnostic testing. You would not use the and since the codes are for an ingestion challenge. Per the CPT guidelines it states for and 96366: "Infusion therapy for therapy prophylaxis or diagnosis..." The answer is yes you may use it. The drug is included in the CPT code for the testing. You should use your diagnosis code Z88.0 for penicillin and Z88.1 for the axithromycin. Both of these diagnosis codes are on the Novitas LCD which covers your geographic area. I think Tricare may follow CMS guidelines. I would recommend you use the "history of or status" code (z code for the anesthetic) for both services. You may use the cough dx for your PFT.

4 Drug Hypersensitivity Under the LCD s for "history of or status" is not listed. Only dx s/sx s are listed. If he had a cough at the time of reaction, but it s not an ongoing issue, could I use cough-r05 or what other code would you recommend? How do you code for inpatient aspirin desensitization consults. If you are being asked for your opinion, you would charge for an inpatient consultation ( ) unless it is a Medicare patient in which case you would need to charge the If you perform the desensitization, you can charge the If you only write the orders and hospital personnel performs the desensitization, you would only be able to charge for the consult. In regards to subcutaneous or intramuscular administered drug challenges, would you bill Correctly, you would bill the X the number of doses or with a 76 modifier for repeat each injectable dose as x of doses OR use x number of doses? procedure. Either way would be appropriate and correct. As an example: Ceftriaxone 10%/90% IM challenge: Administer 10% of daily dose Wait 20 minutes Administer 90% of daily dose Is it billed as x 2 OR x 2 OR an alternative billing code? We are testing for penicillin allergy with a patient and are billing for the ST/ID with code and then test challenge with dosing code How do we bill for the actual medication being used in this testing? Insurance would be Blue Cross of Michigan. I have a young patient whose mother has delayed her receiving her standard immunizations. Mom is concerned that she may have an allergic reaction. Mother had a severe reaction to a vaccine as a child. I would like to offer a vaccine challenge with 10% vaccine administered and then observing for 30 minutes, then 90% vaccine administered plus 30 minutes of observation. We have done this is the past for influenza, MMR, and yellow fever. I just don t know how to code it with the new ICD-10 codes. May I charge separately for PrePen? If so, how? I am not sure reimbursement as it is regularly calculated will cover costs. I just read the article that Teresa wrote called Coding for Penicillin Testing. In that article you state that in order to support oral challenge codes that the patient must be administered a sequential and incremental ingestion of test items. Providing the patient with one oral tablet does not meet the definition of the oral challenge code. The medication used in the testing is included in the value of the codes for testing. You would not have a separate charge for the penicillin." You should code the response the child has to the vaccine - if there is a reaction. Otherwise you will use the Z23 for the vaccination. You may also use the Z code for the family history for the reaction the parent encounter during vaccinations. "If you are allergy testing the patient, the cost of the pre pen is included in the code for the testing- whether it is a skin test or a challenge. If you desensitize you may charge for the drug." The CPT code indicates the need for sequential and incremental doses. If you only provide one dose, it would be included in your E/M services. The physician may have a protocol which will provide a method to administer multiple doses. I am wondering how then should this be done? Is one tablet broken up and given over time ok? Two tablets? What sort of increments or number of tablets are sufficient to meet this definition? Thank you for your assistance. We are going to be performing more of these types of challenges and want to meet documentation requirements.

5 I am writing on behalf my provider located in Louisiana. The insurance company is Louisiana Health Connections and I billed a mod with a The insurance paid for the but denied the saying "reimbursement included in another code per CMS/AMA medical guidelines." I have billed follow up E&M codes with a with other insurance carriers and have not had this problem. LHC will pay for a new patient E&M alongside the but not the return visit. When I called, they stated that the claim had been denied by a analyst and not the computer system and I was wanting to know if you had any advice in what I needed to put in my reconsideration letter to help get this claim payed for and this edit to be resolved for future claims. Does one code for Histamine Control or Saline Control when performing skin testing for drugs or venoms? Regarding coding for Penicillin Testing... Clarification please, are the controls counted as units for or are they excluded? My provider s patient was given an eye drop challenge and the time involved was two hours. The two eye drop solutions that he was tested for were Tropicamide which is the generic of Mydriacyl and Cyclogyl. The drops were placed in his eyes and he was closely monitored. We often use the CPT code (Ingestion challenge) for food but we are not aware of a code for an eye drop challenge or 'installation'. Is there a CPT code for full strength injected challenges for vaccines and medications (lidocaine)? If I do a clinic visit with penicillin skin testing, prick skin tests to foods, and drug challenge for 86 minutes to penicillin on the same day, will I need a modifier 59 for any of the procedures? Please see my coding below and let me know if this is correct. Drug Hypersensitivity You should indicate your E/M was "on and beyond" what was required for your physician to perform the allergy testing. The use of the 25 modifier indicates you have provided services "on and beyond" what was necessary to test the patient. If your documentation indicates those services, you should win your appeal. The controls are included in the drugs and venom testing codes. At this point in time, they are excluded from the units for by the NCCI edits published by CMS. CPT does not have a procedure code for testing for allergies in the eyes. You would need to use the unlisted code - CPT The CPT code is for therapeutic as well as diagnostic injections. I would code for the number of injections administered. Your coding is correct. You shouldn't need any additional modifiers. CPT Name Units M1 M2 M3 M4 ICD1 ICD2 ICD3 ICD Office Visit, Est Pt., Level [1] Z [2] Z PERQ&IC ALLG TEST DRUGS/BIOL14.00 [2] Z PRICK TESTS 6.00 [1] Z INGEST CHALLENGE INI 120 MIN 1.00 [2] Z88.0 Can you please tell me the max units we can bill for CPT code for commercial and government payers? I know the cost of the meds is included in the testing, but when coding for testing done subcutaneously, do we also have to include the J code for the drugs tested against? I have a question, regarding penicillin and other drug testing. Can you/should you bill for the control and histamine? The limit for the number of tests varies by payer. CMS published an MUE of 80 in July of If you are using the CPT code for the injection, the cost of the medication is not included in the value of the code. You would charge for it separately with the appropriate J code. You are limited by CMS to 19 units for the CPT code

6 1. I have a question about using a J code as it relates to penicillin skin testing. Would either of the skin prick or intradermal portions of the test qualify and justify the use of a J code? Also, if within the inpatient setting an IV antibiotic is used in the challenge portion of the test, would this administration of the drug qualify to use a J code? 2. As a follow-up question, would a J code still not be used if whomever was conducting the test chose to skip the oral/iv challenge dose portion of penicillin testing and instead went straight to using their intended therapy dose/and or new medication. For example, if the IV was cephalosporin to treat the patient condition and not a challenge dose, would this change anything? I recently saw a unique case of anaphylaxis after rabies vaccination and rabies IgG administration. Child was referred by ED for evaluation as he required 3 additional rabies vaccine boosters. The evaluation entailed skin testing (scratch and intradermal) and then administration of the vaccine in graded doses because skin testing was positive. We observed between doses and for 1 hour after the challenge was complete. In the past, I have billed both food and medication challenges using 95076, based on time, and I did the same in this case, then second guessed myself since this wasn't an ingestion challenge but IM administration of vaccines. We also billed for the rabies vaccines, IM administration, and skin testing (95018 x 2 units - scratch and intradermals, leaving out completely controls). Is this correct or should I just bill for the number of vaccines used (2 each visit) and number of IM injections + MD face to face time (much less than total time in the office being observed for any reaction). Also, do I bill for controls? (I read with penicillin skin testing one does not as controls are included with the code.) Drug Hypersensitivity 1. "The RVU for the allergy testing codes (percutaneous and intradermal 95018) includes the cost of the medication as part of the test. You would not use a J code in addition for the penicillin for the testing." 2. "If the intent of the encounter is to treat the patient and not test or challenge the patient, the IV therapy codes do not include the RVU value for the medication." You cannot use the and since the challenge isn't oral. You are correct in billing for the IM administration, skin testing (95018) and the vaccines. There isn't any guidance in the CPT book which states the controls are included in the testing, but the CMS NCCI guidelines lead a person to believe the controls are included. If you have face to face time between you and the patient, you may be able to charge for prolong services in addition to an E/M. Your E/M would need to be on and beyond the testing. Until CPT offers us some code for IM and Subcutaneous challenges, you are only able to bill for the injections. Allergy Testing and Challenge Question We have been in discussion with our billing department here about our documentation and billing for food challenges. We have recently been told by our billing department that we should only be billing using OFC codes (95076 and 95079) until the time that the patient reacts. If it is less than an hour, we should only bill for E&M code. We have been told NOT to account for the time spent treating a reaction by billing for the OFC codes. They gave us some indication that we could bill separately for treatment of the reaction through, billing for medications administered, or possibly an E&M code if we provided separate documentation for the reaction. But the documents they gave us discussing this were somewhat unclear. Food Answer According to the CPT guidelines, when the patient has a reaction and you begin to treat the reaction, the oral challenge time stops. You can charge for an E/M for the care given to the patient for the reaction. Your E/M will be based on the history or exam and medical decision making you have documented. In order to bill for the first two hours of an oral challenge, you must have completed at least 60 minutes of the oral challenge. I hope this is helpful. I know that there has been some discussion of this at meetings in the past and I was hoping you might be able to clarify. How should we bill for treatment to a food challenge if the billing stops at the time you decide to treat the challenge?

7 I have a question regarding the ingestion challenge test, CPT I am having trouble finding any current information, I have been reviewing your "New Codes for Ingestion Challenge Benefit Allergy Practice. Old Codes Terminated. New Codes Effective January 1, 2013." My question is when interventional therapies are performed, and the testing is over the 61 minute threshold: Do you bill for both the testing (95076) and the appropriate E/M code? The documentation states "If a patient has a reaction requiring intervention therapy (i. e., injection of epinephrine or steroid) the challenge is over. Any continuing symptoms consistent with a positive challenge test should be reported using appropriate E/M coding. There is no clear directive if the testing is billable with the E/M code. In order to bill an E/M you need to meet the elements, if we count the pretest information for the test portion of the billing, providers would need to have a separate history for the E/M. We are advising NOT to bill for the testing but would like your input and any other current directives for the Ingestion challenge, CPT If a parent brings in a child for peanut allergy testing and has avoided peanut because their sibling has a peanut allergy what ICD 10 code to we use for the skin testing if we need to rule out peanut allergy? Recently, with the publication of the NIH and FDA (and College) recommendations for peanut allergy skin testing in infants, we have received many calls from worried parents. The publication suggested that infants age 4-6 months be tested for peanut allergy prior to eating peanut when there is a strong family history of peanut allergy. Pediatricians in our area are starting to refer for this testing. Food According to CPT guidelines, if an E/M is required, the testing time ends. Also according to CPT guidelines, you would need to be able to support the definition of the 25 modifier which indicates a "separate and identifiable" service is provided "on and beyond" the testing or challenge. The CPT code includes the history and exam required to perform the challenge. Any other services "on and beyond" these guidelines could be charged with an E/M if the documentation supports the services. The documentation for both an E/M and the ingestion challenge would require two separate notes - one for the testing and one for the E/M. I hope this information is useful. There really isn't a good code for this scenario even though it does frequently come up in the allergist's office. There is a screen code for immune disorders Z13.0, or not otherwise specified Z You would need to follow it with the family history code for allergies Z I would also advise the parent, it may not be covered by the insurance depending on their policy. Sorry I don't have a better answer. You may use a screening code for immunology diseases and then follow it with the Z code for family history of allergies. I would also advise the parents the tests may not be covered since the patient doesn't have an active disease. There really isn't any other way to code for this with our diagnoses. My question is how to code the consult and testing. We have been told by our insurance payers and coding literature that we should not bill a visit with "Family History of " (a "Z" code) as the primary and/or only code for the visit. Also, as it would be the only code we would not do any skin testing on that first visit, but have them bring the child back for skin testing, and even then the "Family Hx" code would not be accepted and paid. One of my doctors suggested coding the visit with "anaphylaxis to peanut" even though the child has never consumed peanut thus having no reaction. I am not particularly comfortable with that. Have you had any experience with coding a "Z code" as the only diagnosis for a visit and getting it paid by insurance? Any suggestions as to how to code these visits?

8 Exactly what parameters need to be documented in an ingestion challenge? I know the amounts and times of administration need to be documented, but how often does the patient need to be evaluated, do they need to have vital signs or a physical exam recorded intermittently and if so, at what intervals? I had a billing a question regarding CPT 9076 and 95079; the codes for the oral food challenges. Do you know if you can split bill (professional & technical) the charges for these codes? Food For coding purposes as long as there is a start time and a stop time and a log for ingestion of the food or medication it is fine. There may be a protocol on the AAAAI website under practice parameters which would give you an idea of what specifically you should document." According to the CMS fee schedule the oral challenge (CPT 95076) is a physician service and therefore cannot be split between a professional and technical component. We have a coding question relating to allergy testing when using a fresh food. Can you please clarify what code is appropriate for prink to prick testing when using fresh foods. This is only used when on rare occasion we do not stock the antigen. A food challenge was started at 9:30 and at 10:20 the patient began to have a reaction. I know that the challenge must last at least 61 minutes to be billed. I also understand though that if there is a reaction, the challenge is over. What do I do with these 50 minutes? Can E+M time be billed for this? I know that epi can be billed. Am I correct that patient assessment and monitoring (blood pressure, etc.) after the reaction cannot be reported separately? I am confused regarding when to bill for an office visit for oral challenges. I understand if the challenge is discussed in a prior visit and the only purpose of a visit is the challenge, then no office visit is billed. When is it appropriate to bill for an office visit in addition to the challenge codes? If the patient has eczema that is well controlled, and other food allergies that has not been an issue. Is a brief conversation regarding those other issues is enough to bill for the visit or does it have to be a change made in care or plan? I am having a problem with Total Health Care in getting allergy food testing paid due to diagnosis. Could you help me with a suggestion for allergy skin test diagnosis with symptoms suggestive of food allergies and testing was negative. Have tried T78.1XXA R14.0. They said this cannot be a primary diagnosis. For a food challenge that lasted 134 minutes, after coding for the initial 120 minutes, can I code for the 14 additional minutes? We have a patient who may have a food allergy. We need to report CPT for 100 units. The Medicare MUE is 80. The MAI is 1. The payer follows Medicare guidelines. Is it appropriate in this situation to report x 80 on one line and then x 20 with a modifier on the second line? If yes, what modifier should be used? We thought modifier 59 since each scratch test is for a different food extract or is modifier 76 (repeat procedure) correct? In light of the LEAP study findings, we are getting more and more appointment request for skin testing for younger siblings of known food allergic children. These children often do not have any allergic conditions at baseline (i.e. eczema, asthma, etc) so I find it difficult to find an appropriate billable code to use to justify the skin testing. I do use Z01.82 but I know that Z codes are not billable. You would use the regular prick code. The only other option would be to use an unlisted code but the testing codes only specific per antigen - which can be a fresh food. You can bill an E/M for the entire encounter since you aren't able to bill and oral challenge. You audit your documentation to determine what your history and/or exam and medical decision making for the encounter can support. You may bill for an E/M when the E/M is for any issues other than performing the challenge. Any history taking and exam of the patient to enable you to perform the challenge is included in the challenge. The results and sharing the results are included in the challenge. Any other issues discussed with the patient is billable. If you still are confused, please let me know and I ll try again. You should try only using the sign and symptom diagnosis code and see if it will make a difference. You might also see if the Payer uses the LCD from Medicare to process their claims. In order to code the in addition to the 95076, you need at least another 30 minutes of testing to support an additional hour of coding. You would need to use the 59 modifier to indicate different tests on the second line of You may also need to send notes to indicate the medical necessity of the quantity of the tests. I would disagree with you regarding the use of Z codes as billable. As long as your Z code is for a personal status or history of disease, you should be reimbursed for your services. If there are other diagnosis codes appropriate to the patient, it is also important to use those as well.

9 Are there any non-z codes that would be appropriate in this situation? I am reviewing a case where one of our providers is performing allergy tests for environmental agents and food agents on the same date of service. The provider is billing 70 units with CPT, (skin, prick test); 60 units are billed for environmental allergens and 10 units are billed for food allergens. I have performed some research, but still have yet to determine if these two different test panels can be performed together. When doing skin testing or oral food challenges is it okay to associate these procedures with V codes for food allergy like V15.03 (allergy to egg) or do you have to use another diagnosis code that is not a V code? For Food Challenges what are the appropriate diagnoses to use for coding for the Ingestion Challenge? I have a question about what is required documentation for an ingestion challenge and desensitization. For our practice that would be mostly aspirin desensitization and the ingestion challenge could be a number of different things but mostly food challenges. What do you think is necessary for documentation? I'm assuming initial exam, then how often should vitals be taken? I m assuming time of administration of the food or medication, amount that is administered each time. What does doc need to document along the way? 1. I am wondering if there is a code we can use for an ingestion challenge (95076) for a patient who is at risk for a peanut allergy. They have not had a reaction, so T78.01 would not really apply. 2. This patient has not had a reaction to peanut, and our PA is wondering if risk factors (e.g., atopic dermatitis and egg allergy) would be what we would code? Food I shared your inquiry with our volunteer member leadership. Two responses for your consideration, Food and environmental allergens are often applied at the same time, there is no reason not to do so from a clinician standpoint, as long as the history supports the testing. And, The CPT is not specific to food or aeroallergen and there may be clinical situations, where it is appropriate to test for both - patient with EoE, AR or asthma- and the combination goes on. You may use the V codes for personal history (status) of allergy to foods. You should be able to use either the Z codes for Status of a specific food allergy or the T codes for Anaphylaxis to a specific food. For most payers, those codes are acceptable for ingestion challenges. "For your ingestions challenges you should have a template which gives the initial exam, the initial dose with time of the dose and then the incremental doses as well as the vitals etc. performed during the challenge. You should have the name of the drug or food also. The template should include the ending time and the patient's status at the end of the test. There may be templates available on the internet for you to refer to create your own template." 1. You could use the Z code, Z91.010, for status of peanut allergy if the patient has historically reported a reaction to peanut. Otherwise, you would need to use the complaints (signs and symptoms) which necessitates the testing to peanut. 2. You could use the egg allergy and the atopic dermatitis. I would use the egg allergy first and then the atopic dermatitis. Allergy Testing and Challenge Question I had a question about CPT code (oral challenge 2 hours). I had a patient undergo steroid medication challenge that was conducted with intramuscular administration instead of oral administration. My office manager was informed by Medicare that they would not cover it because the medication of interest was administered intramuscularly. It was a challenge that lasted 1hr 40 min after skin testing was completed. A total of 3 IM doses were administered. Are there other CPT codes that could be used for medication challenges that are not oral? Doctor did an ice cube test to see if a patient had reaction. She put an ice cube on their arm watched for 15 minutes then removed the ice cube and warmed up the arm. What procedure code would I use for such a test? I was asked to verify if there is or is not a code for ice cube test or sandbag test. General Answer For an IM administration for a drug challenge, it is not appropriate to use the CPT CPT is only for an oral challenge. Your coding choices for an IM challenge are either to use the multiple times or use the unlisted code If you use the 96372, you may be able to bill for any face to face time you have in addition to the injections. You would also need a 59 modifier on the CPT to keep it from bundling with the skin testing code. Unfortunately there isn't a cost factor for the ice cube so there isn't a CPT code to describe the ice cube challenge. It would be included as part of the E/M. There isn't a code for an ice cube challenge. You may consider an E/M for the counseling and coordination of care by time but for the sand bag test you would need to have face to face time

10 The ice cube test is approximately 5 minutes, and consists of placing an ice cube on a patient s skin. I do not think there is a code for this, and since it is a minimal amount of time, it should be included in E&M. The sandbag test consists of placing a sandbag on the patients shoulder for approximately minutes to test for pressure-induced urticarial. Since there is a lengthier time component to this test, would it be okay to bill based on time? If the time spent with patient, nature of visit, time spent counseling/coordinating care is documented? How would we bill for prick testing for latex. They did 3 pricks 1 histamine, 1 saline and one saline soaked with a latex glove? 95018? General with the patient for an additional prolong services. If there is an expense such as staff monitoring, etc and a flow sheet for the testing, you could also use the unlisted code in addition to your E/M. You would need to appeal or ask for an allergist review to be reimbursed. The prick test would be appropriate for the If there is an interpretation and documentation of the glove contact with the skin, you could charge one unit of the They also had the patient wear a latex glove for 30 min? Could this be billed with 95044? We have been using the code with a avg. of 100 sticks, but insurance companies are paying for only 30 sticks. Any ideal why and how we can get paid? Do we need to use another code? Should we be using instead of 95028? Can we bill for Elgiloy? It is a specialty metals-strip product that we have to pay for. If so, what codes? Our practice is looking into changing our policy from testing new patients at first appointment to scheduling an evaluation only and returning for testing. Could you share any experience you may have on this? Do you know of other practices that do evaluation only at first visit? And the pros of cons from the billing side of things. We remember at a conference it was mentioned that if you have a patient return for skin test to make sure the provider dictates more on the lines of patient here for allergic rhinitis versus patient returns for skin testing. Is that still the case, did we remember correctly? We performed a challenge to Tdap this afternoon in our office. I was not sure how to bill for it. These are the two scenarios I came up with: (Rapid Desensitization) and (number of pricks and ID's) along with Tdap vaccine or without the Tdap? Or do we bill out the and (Ingestion Challenge) with Tdap vaccine or without Tdap? I have a question about proper coding for patch testing. I typically try to have patch tests placed by our office staff three days prior to a predetermined appointment with me, so that I can read the tests and counsel the patient at that appointment. Your payer is following CMS guidelines for the number of tests allowed per day for the You may want to check and make sure you are performing delayed testing and not the or which have higher limits. Otherwise, you would need to appeal each and every testing with notes to override the edit. If you are performing intradermal testing with readings a short time later on the same day versus delayed you should be using the If you are using the metal to patch test the patient, the cost is included in the value of the CPT code You can t perform the test without the materials. Many practices evaluate new patients and skin test on the same day. If you decide to evaluate a new patient and then have them return for testing on a subsequent day, it is a business decision you are making based on the payers in your geographic area and their payment policies. According to CMS and CPT, you should be able to evaluate a new patient and perform testing on the same day and be reimbursed for both. If the patient returns for testing on a subsequent day, any E/M charged would need to definitely support the 25 modifier definition of "separate and identifiable, and on and beyond" the diagnostic testing. There are a couple of questions you must consider. 1. Did you give the medication orally? If yes, you could bill for an oral challenge if you meet the time components. If not, then you would need to bill for the injections with the if you performed diagnostic injections that were more than percutaneous or intradermal. 2. If you are "challenging" the patient, can you perform the challenge without the medication? If no, then the medication is included such as performing routine allergy testing. I hope this helps you resolve your questions. "You should bill for the patch tests when the patches are placed. If you spend time counseling the patient when you read and interpret the test, you should bill for an E/M." On what day should the patch tests be coded and billed? Should it be the date on which they are placed, or the date on which they are read and interpreted? If I read patch tests, and then spend time counseling the patient on what we are going to do with the results, am I able to bill an office visit on that date as well?

11 We sometimes have problems with patients having the patch test placed and then they don't show up for the appointment. If we don't bill for the patch test when we place them, that means that the tests are wasted and we can't bill for them. That is mostly why I am wondering. Do you have any information regarding the proper billing and coding for CPT I need to know if you can bill along with office visit, 25 modifier, and CPT along with CPT 95044? I am having a lot of issues with commercial insurance and specifically Medicare. If we are billing for vaccine testing: 1. Do we bill for the controls? I know we can't bill Medicare for controls, but is it ok to bill Commercial Insurance for controls. 2 After billing for the (Prick & ID) then proceeding to do a rapid desensitization 95180, do I need to attach a 59 modifier to get both codes paid? I had a question regarding testing of Provoking Factors for Urticaria, like for Demographic, vibratory, cold induced urticaria, etc. I had been told this was not billable and have not seen this charged here. Are there billable codes that would be possible to use for this testing, mostly time spent with the test read and discussed with patient by provider? We recently received a denial from Blue Shield for a skin prick test (95004). They stated " Per CMS payment policy, the positive and negative controls should not be included in the number of tests reported and are not separately counted." Is this correct? Are we not allowed to bill for the controls? Is it ok to bill an E/M code for education time when patient comes back from a previous visit to get just skin testing completed, due to for example having to stop antihistamines? Or can this be billed by time? Example - Doctor had patient come back to do skin testing after off antihistamines and spent 30 minutes with patient discussing and educating, including the interpretation and report. Not really doing history or exam (or minimal, like skin). Doctor asked if the education, plan is part of the RVUs of code First question, if we have a CPT code like does the order of ICD-10 codes matter? We may have J30.1, J45.30, J30.89; however, does the order of the ICD -10 on a claim influence the payment? Second questions, does the number of ICD-10 codes submitted on a CPT code affect the payment amount? Do you have information regarding proper billing and coding for an ice cube skin test and evaporative cooling skin test performed on a patient with Cold Urticaria? I am wondering if most allergists bill for an ice cube test used to diagnose cold induced hives. If so, is there a certain CPT code for this? General You may bill an E/M with both the patch testing and the skin testing codes. You need to make sure you can support the separate and identifiable definition of the 25 modifier to be able to bill for the E/M. If you bill both the and the you will need to have separate and different diagnosis codes. You might check your MAC LCD for diagnosis codes that are covered for and the At this point in time, you should be able to bill for the controls for commercial insurance as long as your number of tests are less than 19. You may need the 59 on the testing, if you perform both the rapid desensitization and testing on the same date of service. The only codes for testing are patch testing and allergy percutaneous and intradermal testing. You may want to use time for counseling and coordination of care to support your services for the E/M. According to the NCCI edits, it suggest controls are not billable. Any services provided on and beyond providing the patient the results of the test are billable. It would be correct to use time for this scenario. If you use one of the allergic rhinitis codes to support your 95117, it wouldn't matter which one was first. You would use the J45.30 only if it is the only diagnosis code and you aren't using it to support and E/M in addition to the Your second question, your payment is determined by your contract with your payer. The number of diagnosis submitted with each CPT code supports the necessity of the level of service you have chosen. The ice cube test is usually included in the level of E/M you are providing to the patient. Most allergist include the ice cube challenge as part of the E/M service. There isn't a specific code for an ice cube challenge."

12 If we use a CPT code or and no other CPT code for an office visit, can we still collect the office copay? I was told that a challenge cannot have an office visit and therefore no copay, if applicable. I also called the insurance company and a rep said that we can charge a copay with procedure code only. Any information that may help clarify this is much appreciated. My provider would like to schedule a patient of his with one of our medical assistants for a level 1 follow up visit so the medical assistant can put on patch tests, billed with code During subsequent visits with the doctor, the doctor will remove the patch tests and interpret the results. Again, interpretation of results takes place at the second and third visits, not at the first visit when the patches are applied. Is it acceptable procedure to provide this service to a patient without the doctor present? I have a coding question for patch testing. We have the order from the Dr. to do Patch test; pt comes in for nurse visit only to have patches applied, and marked and instructions given to the pt. We charge a for that day, should we do vitals for the pt? Have you received any information of BCBS of Texas limiting the units of and 95024? I had a question how to bill for a specific testing I plan on performing. I have an 18 month old child who will be travelling to Ghana and needs Yellow fever vaccine, problem is he is egg allergic (already positive on skin test). The guidelines recommend to skin test for the yellow fever and then administer the vaccine but I am curious which codes would I need for billing. I would not be using the adverse reaction to vaccine since he never received it. What are the proper CPT codes for each day of allergen patch test evaluation? For example, I will put X number of allergen patches on a patient on Monday. I will code only the CPT code for the allergen patch test times number of patches. I do not code an E& M code. The patient comes back on Wednesday for removal of patches and 48 hour patch test reading. I do not code any code for that. I assume that's part of the global CPT for that particular patch test code that I used on Monday 48 hours earlier. The patient then comes back on Friday for a 96 hour patch test reading. I do not charge to read the patches. If I do spend 5, 10 or 15 minutes to discuss the results and print handouts on which ones were positive and discuss treatment, then would I charge a CPT code (E&M) based on time spent? Or is that part of the CPT code of the allergen patch which would've been entered on the Monday when I place the patches (Like a global charge). Please, provide me with information on the correct coding which I have to pass on to the medical assistant who actually submits the CPT codes to the billing department. I want to make sure it's accurate according to proper CPT coding concerning this particular allergy procedure. General You may only charge for an E/M with an oral challenge if the E/M is not related to performing the challenge. Many payers apply deductibles to diagnostic procedures but the patient may also have a co-pay. You will need to check the patient's coverage. It will depend on the patient's insurance. If the patient has an insurance which follows CMS guidelines, the physician needs to be in the office suite. If the payer does not follow CMS guidelines, the physician would not be required to be on site. The requirements, according to the CPT guidelines, for a CPT is a chief complaint. You will also need to have a physician on site for supervision in order to charge the Yes, most BC/BS are following the CMS MUE guidelines. You will need to use the Z23 for the immunization but you should also use the diagnosis code for the egg allergy. You will use the CPT code for medications for the skin testing (95018) and the vaccination codes for the yellow fever vaccine and administration. When you place patches on a patient for a patch test, you would use the CPT x the number of patches when the patches are placed. If the only reason for the encounter is for the patch placement, you would not charge an E/M. When the patient returns in 48 hours and the patches are removed, there is no charge unless there are other issues addressed. At 72 or 96 hours when the final reading is performed and education is provided to the patient, you may charge an E/M. You may want to base your E/M on time as the overarching factor since the majority of your encounter may be counseling and coordination of care.