Allergists often get pushback when trying to bill for an E/M visit on the same day as allergy testing or an oral challenge. Theoretically, you should be able to bill – and get paid for – both services on the same day, assuming they are two significant and separately identifiable services. But many payers routinely deny these claims. So what’s an allergist to do when faced with this situation?
Option 1: Do the E/M visit and the testing on separate days.
Some allergy practices find it easier to simply ask the patient to come back on a separate day for testing if they know a payer won’t cover both services together. This is inconvenient for patients, however, and they may not return for testing. Plus, you need to explain to the patient why you’re asking them to do the testing on a different day.
Option 2: Bill both with a modifier 25 – and be prepared to appeal.
Here are our current recommendations for successfully getting paid for both services on the same day:
- Create two separate chart notes: one for the E/M visit and one for testing. Each note needs to stand alone and support a significant and separately identifiable service. CPT specifically says: Do not report evaluation and management (E/M) services for test interpretation and report. If a significant separately identifiable E/M service is performed, the appropriate E/M service code, which may include new or established patient office or other outpatient services (99202-99215), … should be reported using modifier 25.
- The E/M visit note should document a visit for whatever is bothering the patient. For example, “patient thinks they have allergies,” or “patient is sneezing and cannot work in the spring,” etc. The visit should not be designated as a visit for allergy testing since it would be harder to support an E/M visit at the same time. Do outline the consultation, patient history, symptoms, exam and options for treatment, including why you are recommending testing. No part of the testing process should be included in this note.
- The testing note should document the testing, the test interpretation and test results/report. Document that you explained the risks and benefits of the test and obtained patient consent prior to testing. Avoid reference to the E/M service in this note.
- Following the test, have a shared decision-making conversation with the patient to discuss the test results, the patient’s therapeutic options, and the risks and benefits of each option. Develop an action plan. We recommend documenting this portion of the visit in the original E/M note. Consider billing this E/M visit based on time, which can include the time spent by the physician both before and after the testing (do document the time spent on each). Do not include the time for testing in your calculation of time for the E/M visit.
- A modifier 25 should be appended to the E/M service, indicating a significant, separately identifiable service was performed at the time of the E/M service.
- Many third-party payers insist that testing is a part of an office visit, but this is not the case. You should appeal all denials you believe are unwarranted. Download the sample appeal letter for E&M plus Testing in the College’s Appeals and Denials Toolkit to make this process easier. Failure to appeal could count against you in future denials and result in having other claims flagged for review.
Through dealings with one of the major insurance companies, the Advocacy Council learned that the insurer relies on a computer algorithm to flag modifier 25 claims. Those claims are then sent for review by a nurse/certified coder who looks at the claim and considers it in conjunction with the physician’s history of denials and appeals (but without access to medical records).
If the physician has a significant number of denials and a low appeal rate, it weighs against approval of the claim since it creates an inference that the physician is billing inappropriately. On the other hand, if the physician has appealed a high percentage of denials, and a high percentage were overturned and paid, it is likely the claim will be approved for payment. According to this insurer, about 60% of claims flagged by the algorithm end up being paid upon review by nurse/coders.
The College’s Appeals and Denials Toolkit can help you troubleshoot denials and has sample appeal letters for common allergy visit/procedures denials. Our Coding Toolkit is filled with educational tools and coding FAQs for you and your staff.
