Everything you need to know about coding for oral food challenges

March 18, 2019

Recent studies show the prevalence of food allergy is more than double what was previously reported: a surprising 32 million Americans have food allergies. Given these statistics, providing oral food challenges is an important service allergy practices may want to offer their patients. However, coding for oral food challenges can be a challenge of its own. In a recent College webinar on coding for allergy testing, 30% of attendees named oral challenges as the most confusing allergy testing coding topic. Here’s what you need to know to get reimbursed for this important service.

ICD-10 coding for food allergies

When documenting food allergy status, you can use ICD-10 code Z91.01X. Some common ICD-10 codes include:

  • Z91.010 - Allergy to peanuts
  • Z91.011 - Allergy to milk products (excludes lactose intolerance)
  • Z91.012 - Allergy to eggs
  • Z91.013 - Allergy to seafood (including allergy to shellfish, octopus or squid ink)
  • Z91.018 - Allergy to other foods (including allergy to nuts other than peanuts)

Different insurance carriers require different ICD-10 codes, so check the web site of the carrier to see if they have specific ICD-10 codes that can be used with the CPT codes below.

CPT coding for oral food challenges

CPT 95076 and 95079 are the codes to use for an oral challenge, and they are time-based codes. The challenge must be face-to-face, but it does not require a provider be face-to-face with the patient the entire time; a nurse can meet this requirement.

  • Time begins when the work begins for the oral challenge. That includes providing an explanation of the test, reviewing vitals, reviewing prior reaction history, reviewing the procedure and risks with the patient/family, obtaining consent, etc.
  • Time continues with the food ingestion, assessment and monitoring for allergic reactions (taking blood pressure, doing peak flow tests, watching for rashes, etc.).
  • Time ends either with a negative result or reactions needing treatment (i.e. injection of epinephrine).

95076 is billed for the first 61-120 minutes of the challenge.

  • A minimum of 61 minutes (more than 50% of the total time for the code) must be spent on this challenge before you are eligible to bill this code.
  • If you spend less than 61 minutes on this challenge (for example if a patient has a positive reaction so testing is stopped), bill an E&M code instead, along with the treatment you’re giving (epinephrine, nebulizer, etc.)
  • If you have to stop after 61 minutes for intervention therapy, then you can bill 95076 plus the E/M code and the treatment you’re giving.
  • Note that this code requires “sequential and incremental ingestion of test items,” which suggests at least two doses be used for the oral challenge.

95079 is billed in addition to 95076 after testing has reached at least 151 minutes.

  • It is billable for each additional hour beyond the first 120 minutes of the challenge.
  • An additional 31 minutes (>50% of the total time) must pass before it can be added to 95076. 

It’s rare to bill an E/M code with an oral challenge unless the provider needs to treat for a reaction (intervention therapy – a separate service) or the provider saw the patient for an unrelated office visit the same day as testing. Note this office visit cannot be part of the testing and needs to independently contain at least two of the three key components (history, physical exam and medical decision-making) of an E/M visit for a follow up patient, or all three components for a new patient. You cannot double-count the testing time for both the oral challenge and the E/M code!

If you do code an E/M visit with an oral challenge, add modifier 25 to the E/M code (99212 - 99215).

Excellent documentation is critical for oral challenges. Be sure to document the time testing begins and ends, as well as the amount of food or drug given, any adverse reactions, and discussion of test results. Be prepared to submit your medical records if asked, as denials are not uncommon. Most carriers do cover oral challenges, but many want documentation.

For more information about coding for allergy testing, check out our popular webinar, or access our Coding Toolkit FAQs (on the Interactive Tools tab).

Looking for the latest education on food allergy? Join our Oral Food Challenge: A Primer for the Practitioner webinar, free for members, April 11, 7:00 – 8:00 pm CT. For more education, visit the College Learning Connection and type in “food”. Or use our food allergy slide set to educate your primary care colleagues about this issue.