Billing E/M services with allergy procedures is getting Medicare's attention

If you routinely bill evaluation and management (E/M) services with allergy testing or allergy immunotherapy, expect to receive increased scrutiny from Medicare in the future.

The latest issue of the Medicare Quarterly Provider Compliance Newsletter highlights that recovery auditors have identified this type of coding combination as a potential problem, resulting in what auditors determined were overpayments.

According to the Medicare Claims Processing Manual (Chapter 12, Section 200, subsection C), to receive payment for a visit service provided on the same day that you also provide an allergen immunotherapy service (i.e., any service in the series from 95115 through 95199), you must bill a modifier 25 with the visit code. This indicates that the patient’s condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service you provided. The newsletter also notes that obtaining informed consent is included in the immunotherapy service and should not be reported with an E/M code.

Medicare assumes that allergy injections are typically pre-scheduled and that no other services beyond the injection are usually scheduled at the same encounter. Also, Medicare doesn't believe an E/M code is needed to report the minimal amount of work used to determine if the patient is fit to undergo an allergy injection, believing the injection code already includes that work. However, Medicare recognizes that things don’t always go according to schedule, and you may properly bill for these significant, separately identifiable services using modifier 25 for claims processing.

To see if you're potentially running afoul of these rules, Medicare recommends that physicians pull the documentation for a sample of past instances where they billed Medicare for E/M services tied to scheduled services and compare the “visit intent” against the content of the notes.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians