Documentation Requirements for Allergy Testing 10/29/2018

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Oct 30th, 2018

Per CMS, First Coast Service Options LCD 33261:

Medical record documentation (e.g., history & physical, office/progress notes, procedure report, test results) must include the following information, and be available upon request:

• A complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient.
• The medical necessity for performing the test.
• The test methodology used.
• The measurement (in mm) of reaction sizes of both wheal and erythema response (in vivo testing).
• The medical necessity for the use of in vitro testing if used, instead of in vivo methods.
• The quantitative result (in kIU/L) for specific IgE testing (in vitro testing).
• The interpretation of the test results and how the results of the test will be used in the patient’s plan of care.

Per 42 CFR §410.32, all diagnostic tests must be ordered by the physician/non-physician practitioner who is treating the patient, that is, the physician/non-physician practitioner who furnishes a consultation or treats a patient for a specific medical problem and who uses the results in the management of the patient’s specific medical problem. Tests not ordered by the physician/non-physician practitioner who is treating the patient are not reasonable and necessary.

Providers should not submit additional information with the claim. Information may be requested separately with an additional documentation request (ADR) letter.

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

It would not be expected that all patients would receive the same tests or the same number of sensitivity tests. The number of tests performed must be judicious and related to the history, physical findings and clinical judgment specific to each individual patient.

In vitro testing is covered when medically reasonable and necessary as a substitute for skin testing; it is not usually necessary in addition to skin testing.

In vitro testing (CPT code 86003 and 86008) will be covered for only thirty (30) units per year for medically reasonable and necessary indications as outlined in this LCD. Services exceeding this parameter will be considered not medically necessary.

It would not be expected that more than twenty (20) units be reported for percutaneous testing per year for food sensitivity (CPT code 95004).

It would not be expected that more than forty (40) units be reported for intracutaneous (intradermal) testing (CPT code 95024) per year for a patient.

It would not be expected that more than forty (40) units be reported for intracutaneous (intradermal), sequential and incremental testing (CPT code 95027) per year for a patient.

When photo patch test(s) (CPT code 95052) are performed (same antigen/same session) with patch or application test(s) (CPT code 95044), only the photo patch tests should be reported.

In the event photo tests (CPT code 95056) are performed with patch or application test(s) (CPT code 95044), only the photo tests should be reported.

Click here for a list of CPT Codes that Support Medical Necessity.