Beginning January 1, the Centers for Medicare & Medicaid Services (CMS) expanded its billing policy for HCPCS code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all…
Allergy Testing Medicare Definitions & Coverage
3.
Allergy Testing Medicare Definitions & Coverage
Practice Corner FAQ’s
Q: Is there a maximum number for allergen tests?
A: For an initial diagnostic evaluation, the Centers for Medicare & Medicaid Services (CMS) has determined a limit of <70 prick/puncture tests and up to 40 intracutaneous tests. The CMS L36241 states that the, “number of allergy tests performed should be judicious and dependent upon the patient’s history, physical findings, and provider’s clinical judgment.” [Link below]
For private payers, your best resource is your payer policies and keeping tabs on what was submitted versus what was paid out.
For some payers, the limit may or may not be disclosed in their coverage policies. As a good first step, we recommend reviewing payer contracts to understand what is needed for allergy testing payment, including required documentation and test number limits. As a next step, we suggest monitoring your payers to track what is typically reimbursed compared to the number of tests submitted. This will provide better insights into payer protocols that are not stated in the contract. Additionally, double check which intracutaneous tests are covered. Many limit coverage to 95024 Intradermal testing, which is billed as 1 test per antigen.
We recommend clear and appropriate documentation for all allergy testing, and in any cases where additional tests may be necessary. Note, even with documentation, payment is not assured.
If you have a practice question we can address here, please email [email protected].
Link: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=36241&ver=98
CMS L36241 states:
- The number of allergy tests performed should be judicious and dependent upon the patient’s history, physical findings and provider’s clinical judgment. All patients should not necessarily receive the same tests or the same number of sensitivity tests. Rather, testing should be patient specific based on the history and physical examination.1
- Per evidence-based guidelines, the number of skin tests (e.g., <70 prick/puncture and 40 intracutaneous tests) for inhalant allergens is justified as an initial diagnostic evaluation. Also, up to 80 patch tests may be required for ACD diagnosis.1,8-10
