Medicare Increases Scrutiny of Billing E/M Services With Allergy Testing or Allergy Immunotherapy

Medicare is paying closer attention to organizations that bill evaluation and management codes reported with allergy testing or allergy immunotherapy.

This is according to a recent issue of Medicare Quarterly Provider Compliance Newsletter (pdf), a newsletter from CMS developed to help providers understand the major findings identified by Medicare administrative contractors, recovery auditors and other governmental organizations, such as the Office of Inspector General.

As the newsletter notes, E/M codes reported with allergy testing or allergy immunotherapy are appropriate only if a significant, separately identifiable service is performed. Obtaining informed consent is included in the immunotherapy service and should not be reported with an E/M code. If E/M services are reported, modifier -25 should be utilized.

Recovery auditors have concluded that the services were provided and medically necessary, but the provider billed and Medicare paid for all or part of them more than once.

Here are two scenarios CMS provided to illustrate reasons for adjustments the recovery auditors make to align provider payments with Medicare guidelines:

Example: On August 23, 2012, a professional bill was submitted with E/M code 99214 and Immunotherapy injections code 95117. Finding: The billing of these two codes without modifier 25 to indicate that a significant, separately identifiable service was performed resulted in an overpayment.

Example: On October 25, 2012, a professional bill was submitted with E/M code 99213 and Immunotherapy one injection code 95115. Finding: The billing of these two codes without modifier 25 to indicate that a significant, separately identifiable service was performed resulted in an overpayment.

How to Avoid These Problems
According to Chapter 12, Section 200, subsection C of the "Medicare Claims Processing Manual" (pdf), to receive payment for a visit service provided on the same day that the physician also provides a service in the allergen immunotherapy series (i.e., any service in the series from 95115 through 95199), bill a modifier -25 with the visit code, indicating the patient's condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided.

Medical necessity remains the key as typically allergy injections are pre-scheduled and no other services beyond the injection are scheduled. The injection code includes the minimal amount of work needed to make the determination that the patient is fit to undergo the procedure. However if the patient has a significant, separately identifiable problem that meets the requirements of an E/M service, this may be billed using modifier -25 for claims processing.

CMS advises providers to consider focusing on E/M services tied to typically scheduled services and pull the documentation and compare the "visit intent" against the content of the notes. By monitoring the occurrences of E/M services billed in conjunction with scheduled services, allergist billing errors are less likely.

If you are struggling to properly bill for allergy testing or allergy immunotherapy, consider outsourcing your allergy billing to a medical billing company such as PGM Billing. PGM is a veteran firm with more than 30 years of coding and billing experience. PGM is well-versed in the nuances of allergy billing, and works hand-in-hand with practices to identify problem areas and ultimately ensure they receive proper compensation for services provided.


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