Pediatric allergy services have been on the radar of third-party payer investigations because they have found that many practices incorrectly code and bill for these services. Horizon Blue Cross Blue Shield of New Jersey (“Horizon”) issued guidance for allergy testing effective May 1, 2020. Therein, CPT Code 95004 is referenced and defined as follows: Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests. The number and type of antigens used for CPT 95004 must be chosen judiciously given the patient’s presentation, history, physical findings, clinical judgment and exist in the patient’s environment with a reasonable probability of exposure. The number of tests required may vary widely from patient to patient, depending on the patient’s history. Rarely are more than forty (40) percutaneous tests required.
Importantly, CPT Code 95004 allergy testing will only be reimbursed by Horizon for Allergists, Immunologists or Otolaryngologists or their nurse practitioners or physician assistants working under the direction of one of the above.
In order to avoid billing audits based on allergy testing, the following is recommended:
- Provider practices are urged to check provider agreements before conducting allergy testing.
- Conduct regular internal billing audits to ensure proper compliance
- Develop and implement a formal Fraud, Waste and Abuse Compliance Program and Plan tailored to the needs of your practice.
- Train staff on billing and coding compliance.
Conventus provides legal defense coverage for billing and coding audits. In addition, Conventus strategic partners can assist with developing compliance programs, plans, education, and internal audits. For Conventus insured members, contact the Conventus Practice Advice line or the Practice Resources Department at 877-444-0484, x7466 if you receive notice of a commercial or private audit, investigation, or post-payment demand, or you would like assistance with prevention strategies.