CODING INFORMATION

ICD-10 Codes that may support medical necessity:

D69.0 Allergic purpura 

H10.401 – H10.409 Unspecified chronic conjunctivitis 

H10.421 – H10.429 Simple chronic conjunctivitis 

H10.44 Vernal conjunctivitis 

H16.261 – H16.269 Vernal keratoconjunctivitis, with limbar and corneal involvement 

H10.411 – H10.419 Chronic giant papillary conjunctivitis 

H10.45 Other chronic allergic conjunctivitis 

H10.9 Unspecified conjunctivitis 

J30.0 – J30.9 Vasomotor and allergic rhinitis 

J31.0 – J31.2 Chronic rhinitis, nasopharyngitis and pharyngitis

J32.0 – J32.9 Chronic sinusitis 

J33.0 – J33.9 Nasal polyp 

J45.20 – J45.998 Asthma 

K52.21-K52.29 Allergic and dietetic gastroenteritis and colitis 

K52.89 Other specified noninfective gastroenteritis and colitis 

K52.9 Noninfective gastroenteritis and colitis, unspecified 

L20.0 – L20.9 Atopic dermatitis 

L22 Diaper dermatitis 

L23.0 – L23.9 Allergic contact dermatitis 

L24.0 – L24.9 Irritant contact dermatitis 

L25.0 – L25.9 Unspecified contact dermatitis

L27.0 – L27.9 Dermatitis due to substances taken internally 

L29.8 Other pruritus 

L29.9 Pruritus, unspecified 

L30.0 – L30.9 Other and unspecified dermatitis 

L50.0 Allergic urticaria 

L50.1 Idiopathic urticaria 

L50.6 Contact urticaria 

L50.8 Other urticaria 

L50.9 Urticaria, unspecified 

L56.4 Polymorphous light eruption 

T50.905A-T50.905S Adverse effect of unspecified drugs, medicaments and biological substances T50.995A-T50.905S Adverse effect of other drugs, medicaments and biological substances 

T78.00xA-T78.1xxS Anaphylactic reaction due to food

T78.40xA-T78.49xS Other and unspecified allergy 

Z01.82 Encounter for allergy testing 

Z91.010 – Z91.09 Allergy status, other than to drugs and biological substances 

CPT/HCPCS Codes

Testing: (Laboratory tests are subject to laboratory benefits) 

82785 Gammaglobulin; IgE 

86001 Allergen specific IgG quantitative or semiquantitative, each allergen 

POLICY/CRITERIA

The following allergy tests are covered benefits:

1. IgE Specific Antibody (e.g., RAST, micro-Elisa, immunocap) if clinically indicated for history of severe urticaria, hives, or severe allergy, when skin testing is inappropriate. 

2. Skin tests (scratch, intradermal, pricks) 

3. Patch application tests 

4. Drug Provocation testing 

5. Skin Endpoint Titration (SET). Skin endpoint titration is effective for quantifying patient sensitivity and for providing a safe starting dose for immunotherapy. SET has not been shown to be an effective guide to a final therapeutic dose. 

6. Nitric Oxide Breath Analysis for the management of asthma. 

The following services have not been proven to be effective in diagnosing and/or treating allergies, and are not covered benefits:

1. Cytotoxicity testing (Bryan's test)

2. Urine autoinjection (autogenous urine immunization) 

3. Provocation testing and neutralization therapy for food allergy (intracutaneous, subcutaneous or sublingually). Also called Intracutaneous Progressive Dilution Food Test (IPDFT).  

4. Antigen leukocyte cellular antibody test (ALCAT) for all indications including but not limited to testing for food allergies or intolerance (chemical sensitivities) and as a tool to establish elimination diets. 

5. Electrodermal testing or electro-acupuncture*

Staffing Considerations

There are many variables in determining how to staff your allergy practice and the decisions are specific to the type of practice. The allergy staff is very important to the success of the allergy practice. The allergy assistant, in particular will likely have more interaction with the allergy patient than the physician. The list below is intended to help you with making the right choices for your practice.

• Review state regulations to determine if there are licensure requirements for staff who will perform skin testing, mix treatment vials, and/or give injections
• If your practice is a part of a hospital system, review specific requirements

Qualifications for an Allergy Assistant

• Well suited for frequent patient interaction
•  Inquisitive by nature and able to collect information about progress from patients on an ongoing basis 
• Able to work independently, yet understand when to seek the guidance of the physician
• Committed to learning the technical skills required for allergy testing and treatment 
• Comfortable with observing patients for adverse reactions and following an established protocol for treating adverse reactions 
• Detail-oriented, as needed to set up testing boards, employ aseptic technique, mix treatment vials, maintain records for expiration dates and vial contents, etc.

Educational AND Training Resources

GREER® Resources include

Allergy Testing

• Allergen testing panel recommendations 

1.  GREER® Allergy Map™ (www.map.greerlabs.com) 
2.  Botanical profiles (www.science.greerlabs.com) 

• Consultation to identify optimal required supplies
• Customized testing sheet development 
• Skin testing technique training 
• MQT training (blend of prick and intradermal testing)

Immunotherapy Treatment

• Consultation to identify optimal required supplies 
• Serial dilution training 
• Immunotherapy formulation and dosing consultation 
• GREER® Pharmacy available for Rx service

Understanding the Market

It is important to understand the local market in which your practice will compete. Research into other practices in your geographic area and beyond will help you gain a better understanding of the patient base and revenue potential for your practice. Below is a list of some sources of information for your consideration.

Asthma

Key Statements 

• Asthma is a life-long chronic inflammatory disorder of the airways, associated with variable structural changes, that affects children and adults of all ages. It is associated with airway hyperresponsiveness and airflow obstruction that is often reversible either spontaneously or with treatment. 

• When uncontrolled, asthma can cause death, and can markedly interfere with normal activities, seriously impacting an individual’s quality of life. 

• Because of under-diagnosis and inadequate treatment, asthma presents a serious public health problem throughout the world, especially in low and middle income countries. 

• Atopy - the genetic predisposition to develop IgE-mediated sensitivity to common aeroallergens - is the strongest identifiable predisposing factor to the development of asthma, especially in children. 

• There was a sharp increase in the prevalence, morbidity, and mortality associated with asthma beginning in the 1960’s and 1970’s in the so-called “Westernized” countries of the world. 

• The prevalence of asthma in different countries varies widely, but the disparity is narrowing due to rising prevalence in low and middle income countries as they adopt a more Western-type lifestyle. It is plateauing in high income countries. 

• Inhaled corticosteroids are currently the most effective anti-inflammatory medications to treat persistent asthma. 

• The monetary costs of asthma are substantial and include both direct medical costs and the indirect costs, the latter associated with time lost from work and premature deaths. 

• National efforts to tackle asthma as a public health problem, such as the program introduced in Finland, produce remarkable benefits that are reflected in dramatic reductions in deaths and hospital admissions. 

• Many barriers exist to a reduction in the worldwide burden of asthma. 

• There are unmet diagnostic, therapeutic, educational and financial needs to achieve better worldwide control of asthma.

• More effort is needed to focus on ways to improve the management of asthma by focusing on disease control rather than treating acute episodes. This concept has to be embedded in healthcare programs.

Asthma Definitions and Characteristics 

Asthma is a chronic inflammatory disorder of the airways associated with airway hyperresponsiveness and airflow obstruction that is often reversible either spontaneously or with treatment. There is a strong genetic basis for the susceptibility to develop asthma, however, the impact of environmental factors predominates in determining the prevalence of asthma in a particular population. The genetic predisposition to develop IgE mediated sensitivity to common aeroallergens is the strongest identifiable predisposing factor for the development of asthma, especially in children. Other factors include exposure to environmental tobacco smoke, air pollution, early life respiratory viral infections, certain drugs, and stress. It is important to differentiate the asthmatic state of the airways in affected individuals that is caused by on-going chronic inflammation from acute exacerbations triggered by inadequate treatment and a wide range of environmental factors. 

Symptoms 

Patients with asthma typically experience recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night or in the early morning. These symptoms are usually associated with airflow obstruction which is reversible spontaneously or following treatment. The patterns of these symptoms that strongly suggest an asthma diagnosis are variability, relationship to allergen exposures, precipitation by virus infection and non-specific irritants, such as smoke, outdoor air pollutants, fumes, strong smells or exercise, worsening at night, and responding to appropriate asthma therapy. Presence of a positive family history of asthma or other atopic diseases increases the likelihood that the symptoms are due to asthma, but asthma occurring later in life is often of the non-atopic form. 

Co-morbidities of Rhinosinusitis

Asthma patients, particularly those with severe or difficult to manage asthma, often have concomitant sinusitis. In some studies as many as 65% of severe asthmatics have been found to have evidence of RS on CT. Other observations suggest a nearly universal incidence of sinusitis in patients with severe asthma. The evaluation of moderate to severe asthma should routinely involve a careful review for possible sinusitis, as treating the sinuses may ease the severity of asthma remarkably. 

About 25% of chronic RS patients develop nasal polyps, which are inflammatory growths extending from the sinuses into the nasal cavities. There are several characteristics that distinguish the chronic RS patient with polyps from those that do not develop polyps. Managing nasal polyps is complex and involves a balance between surgery designed to open the ostia and aggressive medical management with corticosteroids instilled into the nose and sinuses and judicial use of antibiotics and oral corticosteroids.

Current and Future Needs

It is evident that physicians do not recognize RS because of the subtlety in identifying the spectrum of symptoms as RS and distinguishing this condition from upper respiratory tract infections/colds or other on-going forms of rhinitis. Better teaching of PCPs, earlier referral to allergists and otolaryngologists, and more use of rhinoscopies and CT scans will enhance our recognition of this important disease.

Some leading specialists utilize liquid suspensions of corticosteroids instilled into the sinuses by lavages in treating RS. Availability of approved formulations of suspensions of corticosteroids would help with this treatment choice. As we try to understand RS better, identification of the characteristics of patients who develop RS, or who then develop nasal polyps, will become more evident and allow us to recognize those patients at higher risk. However, studies of the treatment of RS need higher priority both from governmental agencies and from the pharmaceutical industry. As it stands today, very few medications have been studied or approved for the treatment of RS or related conditions (such as polyps). 

Research Needs 

Little is known about why some patients with acute RS develop persistent inflammation of the sinuses that can persist for years or even a lifetime. Theories about persistent bacterial infections caused by biofilms, bacterial osteitis, or other conditions need to be explored and proven, or discredited. The possible role of Staphylococcus and Streptococcus in chronic RS need to be explored as does the possible role of chronic fungal infections. The role of specific immune abnormalities in patients with recurrent RS needs exploration, as do the immune mechanisms involved in the normal response to RS. Therapeutic medical and surgical approaches need careful analysis and long term assessments.

Unmet Needs 

A large percentage of the population has undiagnosed RS, or inadequately treated RS. Even after establishing the diagnosis, the appropriate guidelines for medical management have not been established and there appears to be too much surgery, performed too early in the course of the disease. Expert guidelines for the diagnosis and management of RS are needed.