Ask the Expert

This month’s selection:
I am asking for your help in clarifying the area of physician and allergy testing in place of service 22, outpatient hospital clinic. Can the physician bill for 95024 when the allergy nurse is performing the allergy testing in this setting? The physician is in the clinic and available if needed.

Is there a difference for place of service 11, physician’s office?

Pamela Nelson, CCS-P
Reimbursement Coding Specialist II
University of Illinois at Chicago

 

Response:
According to section 20.4.5 of the Medicare Internet Only Manual publication 100-02, Chapter 6, Hospital Services Covered Under Part B (on page 13), diagnostic services may be provided “arrangements” in an outpatient clinic and billed to Part B for these services. It is important to understand that allergy testing supervision is based on diagnostic testing supervision guidelines, not incident to guidelines.

Based on the guidelines from Medicare, one would follow the supervision level set forth in the Medicare fee schedule for each procedure. 95024, Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests, requires direct supervision in the Medicare fee schedule, which means that the physician must be in the clinic and immediately available if needed.

Keep in mind, however, that just because the above Medicare supervision guidelines are met does not mean that your state Medicaid and private payers necessarily follow the Centers for Medicare & Medicaid Services’ guidelines. You need to check with your state Medicaid and private payers’ websites to determine whether they have the expectation that their providers follow Medicare guidelines or whether they have different ones. If there is no mention on their respective websites about their expectations for the supervision of diagnostic testing in an outpatient setting nor any mention that they follow all Medicare guidelines, make sure you contact them and obtain clarification as to what their guidelines are. If you receive that clarification verbally, ask for it in writing or send your understanding of the conversation in writing back to the payer, making it clear that you expect to be corrected if you misunderstood any elements of your conversation.

You also should note that some allergy testing requires more than just direct supervision by Medicare. Some testing codes require personal supervision, meaning the physician is in the exam room with the nurse and the patient. These codes include 95060, 95070, 95071, 95075, and 95078.

— Barbara J. Cobuzzi, CPC, CPC-H, CPC-P, CPC-I, CENTC, CHCC, is president of CRN Healthcare Solutions, a medical consulting firm in Tinton Falls, New Jersey. She is a past member of the AAPC National Advisory Board and has been active in consulting, physician and staff education, and evaluating the surgical coding, billing, and payment processes.