The Advocacy Council often receives queries from members on correctly coding specific scenarios. Recently we received a request about coding an oral challenge and an office visit on the same day.
QUESTION
I have been receiving consultation requests for evaluation of penicillin allergy. I typically complete the visit with a history and physical exam. I often skip skin testing and move straight on to a graded oral challenge. I am being told by the billing/coding department that I am not able to enter a visit charge for my E/M service and that I can only charge for the oral challenge. They say that the visit is part of the challenge.
Is this correct? What if I determine during the visit that testing is not safe or indicated? Can I bill for the visit then? If I do the visit with history and physical on one day and bring them back on a separate date for the challenge, is the visit then billable?
My understanding is that my visit is to determine if testing and challenge are appropriate, and that skin testing and oral challenges are separate procedures. Any advice you could provide would be greatly appreciated.
ANSWER
You are correct in that you should be able to bill both the consultation and the oral challenge on the same date of service. You will probably get an initial denial and have to appeal with records that document both the E/M visit (consultation) and the separate testing (skin test/oral challenge). In a note separate from the E/M visit note, document the testing, the results, the patient’s therapeutic options, and your discussion of the risks and benefits of each option. Based on the shared decision-making, develop an action plan. In this note, avoid reference to the E/M service, if possible.
The billing department must use modifier -25 on the E/M visit to show that Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service occurred.
You will have less trouble getting paid if the E/M visit is on a different date of service, but unless the insurance company does not recognize CPT, you should be able to do (and charge for) both services, using the modifier -25.
The description of the oral challenge code includes the wording Patient assessment/ monitoring activities for allergic reaction (e.g., blood pressure testing, peak flow meter testing) are not separately reported – so you may have to explain to the billing and coding staff that the evaluation and management visit is separate from the testing.
The College has coding resources! Check out our Coding Toolkit, including coding webinars and Allergy Office Modules on coding, as well as many other valuable coding resources designed with your allergy practice in mind.
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The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
