95004 – Medicare billing and coding guidance

95004 – Medicare billing and coding guidance

Need information on Medicare billing and coding for percutaneous tests CPT 95004? We’ve got you covered!

CPT 95004: (Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests).

This allergy testing code is reported based on the number of individual tests performed. Therefore, allergists must report the number of separate tests conducted on the claim. The Medicare contractor will multiply the payment for one test by the quantity listed in the unit’s field. Allergists should refer to the payer’s policy to determine if the payer limits the number of units that may be billed for CPT 95004. We advocate for at least the limits mentioned in the practice parameters (70 pricks for inhalants and 40 intradermals).

Medicare does not permit including testing of positive or negative controls in the number of tests reported.1 Positive or negative control tests are not separately billable because they are already included in the medical supply direct input costs for CPT 95004. For example, if an allergist performs a single percutaneous test (CPT 95004), as well as a positive and negative control, only one test may be reported for CPT 95004. Commercial insurance may or may not pay for controls and it is best to check with the individual plans.

Medicare has established limited coverage for CPT 95004. (See How Many MUEs Can Be Billed in a Day.)

For a list of ICD-10-CM codes that support medical necessity and provide Medicare coverage for CPT 95004, please refer to the following local coverage articles:

  • LCA A56559: Palmetto GBA
  • LCA A57531: First Coast Service Options, Inc.
  • LCA A57181: Noridian Healthcare Solutions, LLC
  • LCA A56558: Novitas Solutions, Inc.
  • LCA A57473: Wisconsin Physicians Service Insurance Corporation

Billing requirements for CPT 95004 may vary by payer, so allergists should consult with the payer to determine their billing and coding requirements.

1 Medicare NCCI Policy Manual dated January 1, 2021, under “V. Medically Unlikely Edits #18”.