Popular services like allergy skin testing and immunotherapy can boost the value and revenue of practices that decide to implement them1. However, many allergy companies use inaccurate guidance on billing for allergy services, which often leads to misleading (and sometimes absurd) reimbursement projections. If billing practices are not aligned with clinical protocols nor properly documented, insurance companies could request the return of significant amounts of money. More egregious violations could even lead to audits and criminal investigations.
To avoid these pitfalls, it is important to be aware of and understand the CPT (Current Procedural Terminology) billing codes associated with allergy services, which include skin testing and immunotherapy. Below are descriptions of the codes along with their revenue projections.
Allergy Skin Testing
95004 (Percutaneous Skin Testing) covers the physician & practice expense of performing and evaluating an in-office skin test, which usually involves a single or multi-head device that lightly “scratches” or “pricks” the skin to determine if the patient has a Type I (IgE-mediated) hypersensitivity. The reagents used in this test are comprised of natural extracts from respiratory or food allergens, all of which are paid for through the 95004 CPT code.
The Allerscripts national test panel, for example, tests for 72 indoor allergens. The average cost per patient test is about $75, while the average national Medicare reimbursement rate is $6.05 per test2; thus, a practice can expect a return of $436 per patient test, which amounts to a profit of about $361 per patient test.
To begin reaching an optimal return on investment, we advise practices to schedule a minimum of 2-5 patient tests per week. The following table shows some simple estimates for annual practice revenue and profit.
|2 tests/week||5 tests/week||10 tests/week|
95165 (Provision of Allergenic Extract for Subcutaneous Immunotherapy) covers the physician and practice expense of formulating an immunotherapy prescription. Subcutaneous immunotherapy (SCIT) often requires 1-2 sets of vials depending on the types of allergens being treated. For each treatment set, a therapeutic strength vial labeled “Red 1:1v/v” is created; a series of diluted vials are then prepared to start the patient on a safe concentration of allergens.
Most commercial payers will reimburse for each dose prepared in the treatment set. An Allerscripts’ treatment set includes five vials, which amounts to 54 doses to be administered during the build-up phase of treatment.
A patient who needs 2 treatment sets (for indoor and outdoor allergens) will have 108 scheduled doses (or billable units) of CPT 95165. Using the average national Medicare reimbursement rate of $13.72 per dose2, a practice can expect a return of $1482 for the build-up set of vials.
Medicare defines a billable dose by the volume in the therapeutic (Red 1:1v/v) vial only. When prescribing two treatment sets (2 x 6cc Red 1:1v/v vials), a maximum of 12 units should be billed under CPT 95165. The first-year reimbursement for the build-up set of vials would be about $130 for patients covered only by Medicare*.
*Medicare allows a maximum of 30 units to be billed every 30 days. Practices should not submit the maximum unless 30mL of extract are mixed every 30 days (a very rare situation). Commercial insurance plans have variable restrictions on annual maximums and/or daily, monthly or quarterly limits. Each plan should be reviewed separately.
95115 and 95117 (Administration of Subcutaneous Immunotherapy) cover the physician and practice expense to supervise the administration of immunotherapy injections in the office. CPT 95115 is used when a single injection is administered during the office visit; CPT 95117 is used when administering two or more allergy injections during the visit.
The practice submits a quantity of 1 unit when billing for the CPT code and may submit for reimbursement after each office visit for injections (typically on a weekly basis). Using the average national Medicare reimbursement rate of $10.77 per unit for CPT 951172, your practice can expect a return of $582 after 54 injection visits.
If 20% of tested patients qualify and consent for SCIT, a practice can expect the following estimates for revenue and profit.
|Annual Estimates||2 tests/week||5 tests/week||10 tests/week|
* assumes 2 treatment sets and total reimbursement from CPT 95165 & CPT 95117 after 1 year of treatment
^ assumes a cost of $149/set for standard formulation
The Allerscripts program follows the best clinical protocols and works closely with practices to ensure they properly bill for allergy procedures. If you would like to start offering allergy services at your practice, reach out to us: firstname.lastname@example.org!