Billing and Coding: Allergy Testing

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.