AI Solutions for Healthcare

Identifying Common Allergy & Immunology Billing Schemes

An allergy is a form of exaggerated sensitivity or hypersensitivity to a substance that is either inhaled, ingested, injected or comes in contact with the skin or eye. Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions as well as localized reactions in any part of the body. The reactions may be acute, subacute, or chronic, immediate or delayed, and may be caused by a variety of offending agents; pollen, molds, mites, dust, feathers, animal fur or dander, stinging insect venoms, foods, drugs, etc.

Below are some of the various schemes associated with testing, antigen preparation, administration, and ancillary tests and supplies.

Suspicious Allergy-Related Behavior:

    • Consistently billing the maximum number of tests allowed by plan policy
    • Split billing of the antigen prep, usually a day apart to bypass edits for the annual allotment of allergens
    • Claims with combinations of services for allergy testing, antigen preparation, immunotherapy, evaluation and management services, ancillary tests and supplies
    • Repeat testing
    • Billing A4206 (needles and syringes) used for intradermal testing
    • Always billing an E&M service in association with testing, antigen preparation or injections
    • Billing for allergy testing and antigen preparation but not the injections, which could indicate the provider may have an agreement with an outside vendor to come in to perform the allergy injections

Each of the below codes should be performed in the office setting so the patient can be observed for any reactions.  Documentation should always include the type and number of tests conducted and interpretation of the results. Reporting an evaluation and management service is only allowable if a separate, unrelated service is addressed.

Testing Codes Watch List:

    • 95004- scratch tests
    • 95012- nitric oxide expire gas determination
    • 95017- combination testing (scratch and intradermal) sequential and incremental venoms
    • 95024- intradermal testing with extracts
    • 95027- intradermal testing, sequential and incremental extracts for airborne allergens
    • 95028- intradermal testing with delayed-type reaction
    • 95044- patch testing
    • 95052- photo patch testing
    • 95056- photo test
    • 95060- ophthalmic mucus membrane test
    • 95065- direct nasal mucus membrane test
    • 95070- inhaled bronchial challenge testing

Immunotherapy Injection Codes and Antigen Prep Watch List:

    • 95115- professional services for allergen immunotherapy, single injection
    • 95117- professional services for allergen immunotherapy, 2 or more injections
    • 95120- professional services for allergen immunotherapy in the office or institution of the prescribing physician, including the provision of the extract, single injection
    • 95125- 2 or more injections
    • 95130- 1 stinging insect venom
    • 95131- 2 stinging insect venoms
    • 95132- 3 stinging insect venoms
    • 95133- 4 stinging insect venoms
    • 95134- 5 stinging insect venoms
    • 95144- professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single-dose vial (specify the number of vials)
    • 95145- professionals services for the supervision of preparation and provision of allergen immunotherapy (specify # of doses); 1 stinging insect venom
    • 95146- 2 single stinging insect venoms
    • 95147- 3 single stinging insect venoms
    • 95148- 4 single stinging insect venoms
    • 95149- 5 single stinging insect venoms
    • 95165- professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple agents (specify the number of doses)
    • 95170- whole-body extract of biting insect or other arthropod (specify the number of doses)
    • 95180- rapid desensitization procedure, each hour
    • 95199- unlisted

Claims for antigen preparation and immunotherapy administration should not appear on the same date of service as allergy testing.

How to assess these issues using the Codoxo platform

To surface who your outliers are across all specialties using the Codoxo platform, the tool of choice would be the query tool using the following criteria:

    • Professional Claim Type
      Claims
      Rendering or Billing Entity Type
      Procedure Codes using the Custom Editor feature: (95004 OR 95017 OR 95024 OR 95027 OR 95028 OR 95044 OR 95052 OR 95056 OR 95060 OR 95065) AND (95115 OR 95117 OR 95120 OR 95125 OR 95130 OR 95131 OR 95132 OR 95133 OR 95134 OR 95144 OR 95145 OR 95146 OR 95147 OR 95148 OR 95149 OR 95165 OR 95170 OR 95180 OR 95199) AND (99201 OR 99202 OR 99203 OR 99204 OR 99205 OR 99211 OR  99212 OR 99213 OR 99214 OR 99215) AND (A4206 OR 95012 OR 95070)
      Provider Payment Received minimum, $1
    • Claims
    • Rendering or Billing Entity Type
      Procedure Codes using the Custom Editor feature: (95004 OR 95017 OR 95024 OR 95027 OR 95028 OR 95044 OR 95052 OR 95056 OR 95060 OR 95065) AND (95115 OR 95117 OR 95120 OR 95125 OR 95130 OR 95131 OR 95132 OR 95133 OR 95134 OR 95144 OR 95145 OR 95146 OR 95147 OR 95148 OR 95149 OR 95165 OR 95170 OR 95180 OR 95199) AND (99201 OR 99202 OR 99203 OR 99204 OR 99205 OR 99211 OR  99212 OR 99213 OR 99214 OR 99215) AND (A4206 OR 95012 OR 95070)
    • Provider Payment Received minimum, $1

This custom join works specifically for claim-level queries.
The codes utilized in your query can be switched out or expanded, depending on your policy or health plan knowledge.  The most frequently billed codes were selected above for demonstration purposes.

The following detectors assess individual providers using the power of the AI (Artificial Intelligence): PTP Edit Violations, MUE Violations, Frequent Combinations, Physician Time, Time Behavior, Multiple Claims, Duplicates, and Suspicious Trends.

If you would like more information or set up a demonstration of the Codoxo Forensic Platform, please contact sales@codoxo.com.  
References:
     
    1. CMS Local Coverage Determination- L36402. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=36402
    2.  
    3. AMA 2021 CPT Coding Manual, pages 762 to 764.
     

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