Food OIT is here – how do I get paid?

| September 30, 2019

Food OIT is here – how do I get paid?

The Advocacy Council regularly receives queries from members on how to correctly code specific scenarios. Recently we received a request for assistance from a practice that is looking for direction on correct coding for food oral immunotherapy (OIT). Even though there is pending FDA approval for peanut OIT, a new Level 1 CPT code cannot be obtained until the following criteria are met:

  1. FDA approval.
  2. The procedure or service is performed by many physicians or other qualified health care professionals across the United States.
  3. The procedure or service is performed with frequency consistent with the intended clinical use (i.e. a service for a common condition should have high volume, whereas a service commonly performed for a rare condition may have low volume).
  4. The procedure or service is consistent with current medical practice.
  5. The clinical efficacy of the procedure or service is documented in literature that meets the requirements set forth in the CPT code change application.

Q: Can we use CPT Code 95180 for food oral immunotherapy?

A: The Advocacy Council does not recommend the use of CPT 95180 – Rapid desensitization procedure. This procedure falls under the CPT category – Allergen Immunotherapy (CPT Professional version; pgs. 692-694), and the definition states:

  • Immunotherapy (desensitization, hyposensitization): is the parenteral administration of allergenic extracts as antigens at periodic intervals…
  • Codes 95115, 95117 and 95199 include the professional services necessary for allergen immunotherapy.

Ingestion Challenge Codes – 95076 and 95079

We recommend the ingestion challenge codes for the initial escalation visit only; we do not recommend them for subsequent up-dosing visits. *These are time-based codes. CPT 95076 includes 120 minutes of time. If the food OIT goes beyond 120 minutes, you can use the add-on code 95079 which allows 60 minutes of additional time per unit.

The time calculation begins with the initiation of the procedure. These codes do not require physician face-to-face time, but the physician must be physically present in the office and time should be carefully documented.

Generally, these codes would not be billed following an evaluation and management (E&M) service.

Up-Dosing Phase

For the up-dosing phase (visits about every two weeks), an E&M service can be charged. Each level of E&M is allotted a specific amount of time. When the service goes at least 31 minutes longer than the typical minutes in the E&M code, CPT Code 99354* can be added (includes 60 minutes of time). CPT 99355 can be added for each additional 30 minutes.  

*Time-based codes require more than 50% of the allotted time be used before it is appropriate to charge the code. For example, 25 minutes of physician/NP/PA time is allowed in CPT 99214. To correctly use the add-on code 99354, the physician/NP/PA would need to spend at least 56 minutes face-to-face with the patient. To add CPT 99355, the visit would have to include at least 100 minutes of physician/NP/PA face-to-face time.

The College has coding resources! Check out our coding toolkit on the Member website and our series of coding webinars on the College Learning Connection – designed with your allergy practice in mind.

Do you have a coding conundrum of your own? Ask our coding experts!