Coding and Billing Basics

Modifier 26 – The professional component of a code. This modifier indicates only the professional component of the code is being reported. The technical component may be reported by a different entity. 

Modifier 59 – Distinct procedural services. This modifier is to be used only for procedural services. It indicates a need to report separate non-E/M services individually when normally they are bundled into one code. The most common coding bundling edits are published byCMS asCorrectCoding Edits. Many third party payers follow these guidelines or modify these guidelines to support the payment policies. A common example for the allergist would be when the patient has had a bronchodilation responsiveness test performed (94060) and a separate instruction is given to the patient for a different bronchodilator that the patient will be using at home. Included in the 94060 code is the instruction on the bronchodilator to accurately have a good test. However, if the patient needs a different bronchodilator at home and needs to be instructed on the appropriate technique, then it would be appropriate to code both the 94060 and the 94664 with the 59 modifier attached to the 94664. Modifier 59 is not to be used if another HCPCS modifier best describes the scenario; it is to be used only if no other modifier is appropriate.

Modifier 76 – Repeat procedure by the same physician or other qualified healthcare provider. 

This modifier indicates two exact same services were provided on the same calendar day. The second service received the 76 modifier to indicate the necessity of the repeat services. This is not a modifier to be used on E/M services, but it would be appropriate if two nebulizer treatments were performed on the same calendar day. The appropriate reporting would be 94640, and then 9464076. 

Modifier 77 – If a different provider under the same tax ID provided the repeat service, then the appropriate modifier would be modifier 77. 

If any surgical procedures are performed by the allergist and the procedures have global days associated with the procedures, there would be a need to use additional modifiers for payment of services within the global period. All modifiers are listed with explanations in the appendix of the CPT book and are listed in numerical order for easy reference and understanding.

Coding , Compliance and updates for the practicing Allergist

CPT Changes

Subsection Heading for Allergy and Clinical Immunology “…..which may include new or established patient office or other outpatient services (99201-99215), hospital observation services (99217-99220, 99224-99226), hospital care (99221-99233) consultations (99241—99255), emergency department services (99281-99285) nursing facility services (99304-99318), domiciliary, rest home or custodial care services (99324-99337), home services (99381-99429) should be reported using modifier 25.”

CPT Changes

• Allergy testing Code Changes
• (For administration of medications (eg, epinephrine, steroidal agents, antihistamines) for therapy for severe or intractable allergic reactions, use 96372)
• 95004 – Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests (deleted “by a physician”)
• 95010 and 95015 – deleted
• 95017 – Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal) sequential and incremental, with venoms, immediate type reaction, including test interpretation and report. Specify number of tests
• RVU value 2.52
• 95018Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal) sequential and incremental with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of test.
• RVU value .86
• 95024, 95027 – Deleted the wording “by a physician.”
• New subsection – Ingestion Challenge Testing 

New Subsection – Ingestion Challenge Testing

• Codes 95076 and 95079 are used to report ingestion challenge testing. Report 95076 for initial 120 minutes of testing time (ie, not physician face to face time). Report 95079 for each additional 60 minutes of testing time …
• For total time less than 61 minutes (eg positive challenge resulting in cessation of testing). Report an evaluation and management service if appropriate.

Ingestion Challenge Testing

• Patient assessment/monitoring activities for allergic reaction are not separately reported. Intervention therapy (eg injection of steroid or epinephrine) may be reported separately as appropriate.
• For purposes of reporting testing times, if an E/M service is required, then testing time ends.

CPT Changes

• 95076 – Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); initial 120 minutes – RVU value 3.42
• +95079 – each additional 60 minutes of testing RVU value 2.41
• Time will need to be documented in the testing document to support the coding
• 95120 – 95134 – added “in the office or institution of the prescribing physician or other qualified health care professional” including allergenic extract:…
• Pulmonary Coding Changes
• Subsection instruction changes – same as allergy section for definition for E/M billing in addition to pulmonary billing
• 94014, 94016 added ….physician or other qualified health care professional” to the code description.
• Miscellaneous Code changes
• 99000, 99001 – Handling and/or conveyance of specimen for transfer from the office to a laboratory…..delete “physician”

CPT Changes – Evaluation and Management Codes

Added the phrase “other qualified health care professional who may report evaluation and management services reported by a specific CPT Code”

Evaluation and Management Codes

“In the instance where a physician/qualified health care professional is on call for or covering for another physician / qualified health care professional, the patient encounter will be classified as it would have been by the physician qualified health care professional who is not available. When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same subspecialties as the physician”

CPT Changes

• Evaluation and management Code Changes
• Added the phrase “other qualified health care professionals to all code descriptions
• Category II CPT Code changes
• 3750F Patient not receiving dose of corticosteroids greater than or equal to 10mg/day for 60 or greater consecutive days

Evaluation & Management Codes

1. Chronic Care coordination Services
2. 99487- 99489

E/M Codes – 99487-99489 (Bundled by CMS Fee Schedule status)

• 99487-99489 includes:
• Communication (with patient, family members, guardian or caretaker, surrogate decision.makers, and/or other professionals regarding aspects of care.)
• Communication with home health agencies other community services utilized by the patient.
• Collection of health outcomes data and registry documentation.
• Patient and/or family/caretaker education to support self management, independent living, and activities of daily living .
• Assessment and support for treatment regimen adherence and medication management.
• Identification of available community and health resources.
• Facilitating access to care and services needed by the patient and/or family.
• Development and maintenance of a comprehensive care plan.

E/M Codes 99495-99496 Transitional Care Management Services

Requires face to face encounter, initial patient contact and medication reconciliation within specific time frames. TCM requires an interactive contact with the patient or caregiver, as appropriate, within two business days of discharge. May be direct, telephonic, or by electronic means. Medication reconciliation and management must occur no later than the date of the face to face visit.

• 99495 – Transitional Care Management Services.
• Communication with the patient and/or caregiver within 2 business days of discharge.
• Medication decision making of at least moderate complexity during the service period.
• Face-to-face visit, within 14 calendar days of discharge.
• 99496 – Transitional care management services.
• Communication with patient – 2 business days.
• Medical decision making of high complexity.
• Face to face visit, within 7 calendar days of discharge.