Allergy Testing: Supplies & Services

April 19, 2024 | By: Beth Schleeper, COC, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, CPC-I, CEMC, CANPC, CEMA, CMCS, CMRS

AHHHHHCHHOOO! The sound of Spring and Allergies is in the air. If you are like many of us, you have these pesky critters year-round. So how do we report for the services and supplies? Grab a Kleenex and a Claritin as we break down the guidelines.

Allergy testing should not be performed on the same day as allergy immunotherapy according to standard medical practice. Instead, allergy testing must be performed before immunotherapy, 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.

The unit of service is important when reporting allergy testing. Be sure to read and understand the definition of your chosen CPT codes. Most testing codes indicate “Specify the number of tests”. This will be your quantity of units reported. When reporting Immunotherapy, it is important to choose the code(s) with the correct allergen extract as well as the correct number of injections performed.

Payers will reimburse for medically necessary clinically indicated allergy testing and allergy immunotherapy services. Be sure your documentation indicates the need for the testing. Remember, accurate reporting ensures proper reimbursement and compliance with billing rules.

Some allergy testing is specifically excluded from allergy testing billing due to regulations and guidelines so be sure you are adhering to your payer rules.

Typically, allergy testing is performed by medical assistants, nurses, nurse allergists (specialty certification in nursing), and other non-physician providers. You may think these ancillary staff and non-physician providers are working and billing under the incident-to rules, but their services actually fall under the diagnostic services supervision rules, which require the practice to provide them with either “general,” “direct,” or “personal” supervision. Although these levels of supervision are the same as described in incident-to services, a different set of rules apply to diagnostic services. Each diagnostic CPT® code is assigned a supervision level requirement in the Medicare Physician Fee Schedule (MPFS) database depending on the perceived risk of the procedure.

Admin of Allergy Immunotherapy – Administering allergy immunotherapy, commonly known as “allergy shots,” can be performed in a variety of ways. Some allergy practices give the patients serum vials to bring to their primary care physician (PCP) to administer the shots according to the treatment plan. Some providers let the patients self-administer the shots, while other allergists say they consider patient self-administration to be unsafe.
When the provider who makes up the serum is also the administer of the allergy shots, the provider may make up the sequentially diluted serum sets that are specific to the patient and then administer first from the most diluted vial, moving on to the next most diluted vial, and eventually up to the maintenance vial. The payer pays for the serum up front for 95145-95180 (and most often 95165), times the number of units billed. Then, the practice bills one of the two injection codes (95115-95117). Note that 95117 is not an add-on code: Do not report 95115 with 95117; one or the other is coded, not both.

Many insurance companies limit the number of allergy tests that may be performed at a single session and may set medical necessity requirements for sequential and incremental SET testing. Be sure to review each payer’s guidelines on their website, so your practice knows the limitations and medical necessity requirements, BEFORE rendering care.

Evaluation and management codes which are reported with allergy immunotherapy or allergy testing can only be used when a separately identifiable service is provided. In such cases, modifier 25 must be utilized.

Happy Allergy coding Friends!