“If It Is Not Documented”

As featured pre-work for our 2024 Annual Meeting, Teresa Thompson and Robert Puchalski, MD, FAAOA discussed some common coding conundrums. While we encourage you to register for the meeting for full access to the presentation, here are some conundrums and solutions they shared.

Myths & Urban Legends:

Ignore Audits:

Far from it. Audits are an opportunity to both learn and educate.  Rather than bristle and approach an audit in a defensive posture, consider it an opportunity. Many payers have no clue what you do or what is entailed in allergy diagnosis and management. Many are just following their internal protocols for review and denial. So while it is frustrating to have payment denied or to get audited, it is in your best interest to respond and help find solutions.

Audits beget more audits:

This is true if you do not respond. You have been audited because some anomaly was flagged. If you do not respond, payers will continue to flag you as a problem. If you respond and learn how to improve coding, billing, documentation, or whatever the problem was, they will note the improvement and more than likely leave you alone.

Bill an Nurse Education Code at the time of the Allergy Injection:

Unless you can document a reason or necessity, you are flagging yourself as overcoding or over billing. Yes. There is a nurse education code (CPT code 99211) but it has to be tied to something more than the weekly allergy shot.

Bill your vial prep at the time of testing under the ordering physician:

No. You will see the patient for testing, and based on your (the physician’s) interpretation of the results, you will write out your prescription for immunotherapy. Your recipe, so to speak, for what should go into the immunotherapy vial. But unless the vial is physically made that day, do not bill it that day. In fact, many payers look for vial prep billed on the same day as testing and flag it for denial. Allergy immunotherapy vial prep (CPT code 95165) must be billed on the day the vial is made under the supervising physician. This is the physician who is in the office and incident to the vial prep.  It may not be the ordering physician. Keep in mind there is physician work in the code and it falls under incident to and direct supervision.

Ms. Thompson and Dr. Puchalski emphasized the need to good documentation. This includes the documentation cited in USP General Chapter <797> requiring antigen lot numbers, BUDs, mixing logs, and vial BUD dates (earliest BUD of any component in the vial). See AAOA resources on USP General Chapter <797> here.

For more insights into common coding conundrums, register for the AAOA Hybrid Annual Meeting to access this session and more.