AAOA

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AOALLERGY

.ORG PRACT ICE

RESOURCE

TOOL K IT

Materials presented in this tool kit are intended as

resource only and should not be construed as guidance

Allergy Coding

AAOA Practice Resource Tool Kit

Allergy Coding

CommonAllergyCodes—Testing(AMACPTCodes):

95004 SkinPrickTest 1stick/antigen

95024 IntradermalTest 1stick/antigen

95027 IntradermalDilutionalTesting

Multiplesticks/antigen

86003 InVitroTest Onlybillableifperformedinoffice;cannotbilllabwork

95017 Venoms—New Anycombinationofpercutaneous(scratch,puncture,prick)&intracutaneoussequentialandincremental,immediatetestreaction

95018 Biologicals&Drugs—New

Anycombinationofpercutaneous(scratch,puncture,prick)&intracutaneoussequentialandincremental,immediatetestreaction

AllergyCPTTestingCodes:95004

• CPTDefinition:Percutaneoustests,(scratch,puncture,prick)withallergenicextracts,immediate-typereaction,includingtestinterpretationandreportedbyaphysician,specifynumberoftests

• CPT2008revisedguidelinetosupportthathistoryandphysicalservicesarenotincludedinthiscodeandthatanE/Mserviceshouldnotbereportedseparatelyfortheinterpretationandreport.

– “includingtestinterpretationandreportbyaphysician”addedtodescriptor• AnE/Mcanbebilledinadditiononlyifaseparateanddistinctserviceisperformed

95024• CPTDefinition:

Intracutaneous(intradermal)tests,withallergenicextractsforairborneallergens,immediate-typereaction,includingtestinterpretationandreportbyaphysician,specifynumberoftests

• CPT2008revisedguidelinetosupportthathistoryandphysicalservicesarenotincludedinthiscodeandthatanE/Mserviceshouldnotbereportedseparatelyfortheinterpretationandreport.

– “includingtestinterpretationandreportbyaphysician”addedtodescriptor• AnE/Mcanbebilledinadditiononlyifaseparateanddistinctserviceisperformed• IntradermalCodes(95024/95027)donotcoverfoods;Airborneonly

95027• CPTDefinition:

Intracutaneous(intradermal)tests,sequentialandincremental,withallergenicextractsforairborneallergens,immediate-typereaction,includingtestinterpretationandreportbyaphysician,specifynumberoftests

19Materials intended as resource only and should not be construed as guidance. AAOA Practice Resource Took Kit

AAOA Practice Resource Tool Kit

• CPT2008revisedguidelinetosupportthathistoryandphysicalservicesarenotincludedinthiscodeandthatanE/Mserviceshouldnotbereportedseparatelyfortheinterpretationandreport.

– “includingtestinterpretationandreportbyaphysician”addedtodescriptor• AnE/Mcanbebilledinadditiononlyifaseparateanddistinctserviceisperformed• If>1dilution/antigen;mustuse95027• DonotrefertoasSETorSkinEndpointTitration• TermsSET&Rinkel=NonCoveragebymanycarriers• IntradermalCodes(95024/95027)donotcoverfoods;Airborneonly

CodingVignettesNote:Eachpracticeisresponsibleforconfirmingcoverage,coding,andpaymentparametersforthosepayersthataffectthepractice.Thesevignettesarecitedasexamplesonly

• Allcodesarebilledusingthenumberofsticksortests/antigen• Manycarriershavestrictinterpretationsofhowtestingcodesdiffer• ForIDtesting,

– ifonlyperform1stick/testperantigenconsideredstraightintradermal=95024– Twoormoresticks/testsperantigenconsideredintradermaldilutionaltesting=95027

Foreachantigen/sameday,– Youcanbill

95004+95024or95004+95027

– Youcannotbill95004,95024,+95027or95024+95027

– Billingauditsarebasedoncorrectcodeusage

– Carriershavelimitsonthenumberoftests:• Billedatonetime• Billedwithinacertaintime(year)

– Billinginexcessofcarrierlimitsmayrestrictpaymentorbeflaggedforaudit

– Recommendrequestingcurrentallergypaymentpracticesfromcarriers

SampleBillingfor14AllergenTestBattery• Percutaneous(Prick)Testing—95004X14units• IntradermalTesting(ID)—95024X14(1test/antigen)• IntradermalDilutionalTesting(IDT)—95027X42units(assumes3dilutions/antigen)

InVitroTesting• MostMedicarecarriersandprivatepayerscurrentlycoverIVTasasecondlineoptiontoskin

pricktesting• Keytocheckforpolicyupdates;Somemayhavedefinedrestrictions• BillingisunderCPTCode86003• IVTmustbeperformedinthephysician’sofficetobill• Iflabperformstest,onlybillblooddraw

20Materials intended as resource only and should not be construed as guidance. AAOA Practice Resource Took Kit

AAOA Practice Resource Tool Kit

Supervision• Alldiagnostictestsareassignedalevelofsupervision

– General:Physiciandoesnotneedtobeonpremise,buthavemanagementresponsibilityforstaffwhodoesthetest

– Direct:Physicianneedstobeintheofficesuite,butdoesnotneedtobeintheroomwhenthetestisdone.

– Personal:Physicianneedstobeintheroomwhenthetestisperformed

• AllergytestsareunderDirectSupervision

AncillaryStaff:ScopeofPractice• Nursepracticelawsandregulationsarespecifictoeachstate.• AANPoffersquickreferenceguideforlicensureandregulatoryrequirements,aswellaspractice

environmentdetails,forall50statesandtheU.S.Territories.DownloadableStateRegulatoryMapavailableatwww.aanp.org

• AAPA’swebstoreoffers“PAStateLawsandRegulations"includesall50statesandtheDistrictofColumbia.www.AAPA.orgoffersasynopsisofeachstate’sPApracticeact,includingscopeofpractice,prescribingandsupervision,amongothertopicsthatcoverPApractice.

• RecommendcheckingwithstatenursingboardtoconfirmscopeofpracticeandwhetheranNP/PAcansuperviseanotherstaffmembertestingortreating

Asanexample,NPScopeofPracticeisdefinedas:• FullPractice:Evaluatepatients,diagnose,orderandinterprettests,initiateandmanage

treatmentsundertheexclusivelicensureauthorityofthestatenursingboard• ReducedPractice:ReducestheabilitytoengageinatleastoneelementofNPpractice(above)

andrequirescollaborativeagreementwithanoutsidehealthdisciplinefortheNPtoprovidepatientcare

• RestrictedPractice:RestrictstheabilitytoengageinatleastoneelementofNPpractice(above)andstaterequiressupervision,delegation,orteam-managementbyanoutsidehealthdisciplineinordertoprovidepatientcare.

CommonAllergyCodes—Immunotherapy(Treatment)(AMACPTCodes):95004 SkinPrick 1stick/antigen95024 lntradermal 1stick/antigen95027 IDT Multiplesticks/antigen95115 SingleShot SingleInjectionlmmunotherapy

Singleshotfromsinglevial95117 MultipleShot TwoormorelmmunotherapyInjections

Singleshotfrommultiplevial;noX's95165 VialPreparation BillX#units

Medicareexception:Dosedefinedas1ccregardlessofactualdosagedelivered

95144 VialPreparation Singledosevial

21Materials intended as resource only and should not be construed as guidance. AAOA Practice Resource Took Kit

AAOA Practice Resource Tool Kit

ImmunotherapyCodesAdministration

• CPTCode: 95115Professionalservicesforallergenimmunotherapynotincludingprovisionofallergenicextracts;singleinjection

• CPTCode: 95117Professionalservicesforallergenimmunotherapynotincludingprovisionofallergenicextracts;twoormoreinjections

Reporteither95115or95117duringasinglepatientencounter.Ifoneinjectionisgiven,report95115(only).Iftwoormoreinjectionsaregiven,report95117(only).

Preparation• CPTCode: 95165

Professionalservicesforthesupervisionofpreparationandprovisionofantigensforallergyimmunotherapy;singleormultipleantigens(specifynumberofdoses)

• CPTCode: 95165Describesthepreparationoftheantigen,theantigenextractitself,andthephysician'sassessmentanddeterminationoftheconcentrationandvolumetousebasedonthepatient'shistoryandresultsofpreviousskintesting.Thesecodesrequirethatthenumberofdosesbespecified.

CodingVignettes• CPTCode: 95165

Professionalservicesforthesupervisionofpreparationandprovisionofantigensforallergenimmunotherapy;singleormultipleantigens(specifynumberofdoses)

– 95165Xunits– Units=dosesfornon-Medicarecarriers– Units=ccforMedicare– Note:SeveralprivatepayershaveadoptedMedicareinterpretation

• Non-MedicareClinicalExample:– Physicianprepares10-dosemultidose5ccvialforapatient.Sameencounter,1doseis

administeredvia1injection– 95165X10inunitsboxand1injectioncode:95115

• MedicareClinicalExample– Physicianprepares10-dosemultidose5ccvialforapatient.Sameencounter,1doseis

administered– 95165X5inunitsboxand95115

• CMSinterpretstheunitasa“billabledose,”notaclinicaldose.

• CMSbillabledoseisequalto1cc– 5ccvial=5unitsnomatterhowmanydoses

22Materials intended as resource only and should not be construed as guidance. AAOA Practice Resource Took Kit

AAOA Practice Resource Tool Kit

• CPTCode: 95144Professionalservicesforthesupervisionofpreparationandprovisionofantigensforallergenimmunotherapy,singledosevials(s)(specifynumberofvials)

• CPTCode: 95144Describesthepreparationandprovisionofextractfurnishedinasingledosevial(s)bytheallergist/otolaryngologistforadministrationbyanotherphysician.Singledosevialscontainasingledoseofantigenthatisadministeredinoneinjection.

• CPTCode: 95144Describesthepreparationandprovisionofsingle-dosevialsofantigenstobeadministeredbyanotherphysician.

• Singledosevialscontainonedoseofantigentobeadministeredinasingleinjection.• Vialsaredesignedforusewhenthereisconcernabouttheaccuracyofmeasurementof

dosesfromamultidosevialbyanon-allergist.• Numberofsingledosevialspreparedandprovidedshouldbespecifiedwhenreporting

thiscode.

CodingVignettes• 95144Vignette

– Youpreparetwosingle-dosevialsofallergenicextractforapatientwhoplanstotraveltoanothercitywithinhisstateduringthetimehistwodifferentallergyinjectionsaredue.

– Yourstaffpackagesthevialsalongwithrelevantstorageandotherinformationandgivesthemtothepatient.

– Severalweekslater,aprimarycarephysicianinanothercityadministersthetwoallergyinjectionsfromthesingledosevials.

– Youreportcode95144withthenumber2intheunitsfieldoftheclaim,specifying,accordingtothecode,thenumberofvialspreparedandprovided.

Theprimarycarephysicianreportscode95117withthenumber1intheunitsfieldoftheclaim,indicatingthattwoormoreinjections,exclusiveofthesupplyofantigen,wereadministeredatthatvisit.

PerCPTGuidelines(2005Edits):

”Officevisitcodesmaybeusedinadditiontoallergenimmunotherapy,ifotheridentifiableservicesareprovidedatthattime"

NCCIProceduretoProcedure(PTP)edits• Focus:Codes95115-95180(allergenimmunotherapy)withCodes95004-95079(allergytesting

&ingestionschallenge• Assumptions:Testingprecedesimmunotherapybyatleastoneday• CMSwillallowuseofNCCI-associatedmodifiersforthe“uncommon”scenariowhereapatient

needstobetestedforreactionstoadditionalallergensonsamedayofservice• Physiciansmayperformintradermaltestingwhenanewvialisused(e.g.,vialtest).• ThisisNOTseparatelyreportablewithanallergytestingcodesinceCMSconsidersthisquality

control(safetycheck)tobeaninherentcomponentofimmunotherapy• VialTesting:NCCIPolicyManualstates:

23Materials intended as resource only and should not be construed as guidance. AAOA Practice Resource Took Kit

AAOA Practice Resource Tool Kit

“PhysiciansshouldnotreportallergytestingCPTcodesforallergenpotency(safety)testingpriortoadministrationofimmunotherapy.Confirmationoftheappropriatepotencyofanallergenvialforimmunotherapyadministrationisaninherentcomponentofimmunotherapy”

Supervision• Code95165&95144describethesupervisionandprovisionofantigensforallergy

immunotherapy,whethersingleormultipleantigens• Supervisionreferstodirectsupervision,meaningthephysicianneedstobeintheofficesuite,but

doesnotneedtobeintheroom.• Immunotherapyservicesare“incidentto”,requiringdirectsupervisionwithintheofficesuite• Nursepracticelawsandregulationsarespecifictoeachstate.

– AANPoffersquickreferenceguideforlicensureandregulatoryrequirements,aswellaspracticeenvironmentdetails,forall50statesandtheU.S.Territories.DownloadableStateRegulatoryMapavailableatwww.aanp.org

– AAPA’swebstoreoffers“PAStateLawsandRegulations"includesall50statesandtheDistrictofColumbia.www.AAPA.orgoffersasynopsisofeachstate’sPApracticeact,includingscopeofpractice,prescribingandsupervision,amongothertopicsthatcoverPApractice.

– RecommendcheckingwithstatenursingboardtoconfirmscopeofpracticeandwhetheranNP/PAcansuperviseanotherstaffmembertestingortreating

Asanexample,NPScopeofPracticeisdefinedas:• FullPractice:Evaluatepatients,diagnose,orderandinterprettests,initiateandmanage

treatmentsundertheexclusivelicensureauthorityofthestatenursingboard• ReducedPractice:ReducestheabilitytoengageinatleastoneelementofNPpractice(above)

andrequirescollaborativeagreementwithanoutsidehealthdisciplinefortheNPtoprovidepatientcare

• RestrictedPractice:RestrictstheabilitytoengageinatleastoneelementofNPpractice(above)andstaterequiressupervision,delegation,orteam-managementbyanoutsidehealthdisciplineinordertoprovidepatientcare.

References:1. CMS Manual

http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

2. AMACPT2005ProfessionalEdition,page374

3. AMACPT2008Changes:AnInsider’sView

4. NCCIPolicyManual,Chapter11,SectionK,4

5. http://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment

6. http://www.aapa.org

24Materials intended as resource only and should not be construed as guidance. AAOA Practice Resource Took Kit

Note: AMA CPT Editorial Panel maintains CPT. A new version of the CPT Book is issued annually.