After running test claims to address doubt about reimbursement on the relevant CPT codes for primary care allergy testing, the next step in maximizing confidence in the decision to authorize an allergy program—that allergy makes financial sense—is ensuring medical necessity documentation will be squared away in the ordinary course without extra effort or friction. Stating the obvious, well documented medical necessity is a requirement for smooth claims reimbursement, and, if the time comes, audit defense. A proper, comprehensive, turnkey allergy program makes this part seamless.
Patient Symptom Survey and Treatment Options are Crucial
Two preliminary observations are warranted.
One is that best practice, gold standard allergy diagnosis includes medical history for purposes of interpreting diagnostic test results. The American College of Allergy, Asthma, & Immunology puts it plainly: “Allergy skin testing is the gold standard and is used along with the medical history to find out exactly what things a person is allergic to.” That history thus serves a dual role, one in clinical diagnosis, the other in billing, and it is therefore doubly important. Further that history is supplied or dominated by the patient symptom survey. Those tasked with making a confident, prudent decision about adding an allergy program will want to understand that the patient symptom survey is the lynchpin of any successful allergy program—it’s central, indispensable, and, luckily, easy.
The other is that even perfectly documented medical necessity for allergy testing can develop a soft spot for audit defense in the absence of treatment offerings when the test result is positive. From an auditor’s perspective, if there’s no evidence that the clinic has even discussed treatment with a patient who’s just been diagnosed as allergic, that’s a red flag. The rationale is that testing might be strictly for money, not medicine, if there’s not even discussion, let alone execution, of treatment options. Therefore treatment options should be documented as well.
The Four Elements of Documented Medical Necessity for Allergy Testing
Clean allergy test claims require four core elements of documented medical necessity. They are: the survey, the clinical decision, the diagnosis, and consistency. The first is something the patient does. The next is just reading and signing off if what the patient did indicates testing. After that, just code it and be consistent.
1. The Patient Symptom Survey
A structured allergy symptom questionnaire (Pt Sx Survey, or patient symptom survey) establishes that the patient has signs or symptoms consistent with allergic disease. The survey ought to document the presence of chronic symptoms, their severity, and any recurrence pattern, that in concert justify testing. Symptoms to consider in such a survey run the gamut from garden variety sneezing or itchy eyes, which almost everyone associates with allergy, to more enigmatic symptoms like brain fog, bags under the eyes or frequent infections (downstream of overworked immune systems).
Alternatives to a survey completed by the patient exist, but a moment’s consideration raises doubts. The alternatives include structured history-taking with written notes (really just a verbal version of the written survey), or a written history based on conversation and the patient’s prior recorded history chart.
These alternatives differ from the questionnaire in two key aspects: provider involvement and repeatability. A patient can complete a survey based on a list of potential symptoms and soliciting presence, severity, and periodicity, before arriving at the clinic. Or it can be a single sheet of paper and completed in the waiting room along with the rest of medical history. Then 12 or more months later, that patient will complete the same survey again—the same survey every time—the only variability is how the patient answers it, or how it’s presented (e.g. going from paper to digital). And, the provider is not involved yet.
In contrast, interviewing the patient and/or reviewing the prior history requires a provider to do the interviewing and reviewing. Further, the next time the survey is due, the likelihood that the same provider will perform those tasks must be considered. Even if it’s the same provider, it’s unlikely the same questions will be asked in the same way, or that the same parameters for the history review will be applied and faithfully executed. The fact is that human variability is such provider-centric approaches to the survey—as opposed to its interpretation—compromise repeatability and therefore reliability, and any adverse impact of that variability compounds when repeated annually. Finally, the standardized, patient-completed survey also provides a solid foundation for a conversation with the patient, and it becomes part of the chart.
2. Clinical Decision to Test
Clinician review of the survey (and any prior testing or treatment) and ordered the skin test. A short note such as “Allergy symptom survey positive for perennial and seasonal symptoms; skin testing indicated to guide management” is usually sufficient. The order itself, signed or electronically authenticated, is critical.
3. Appropriate Diagnoses
Link the claim to ICD-10 codes that support medical necessity for allergy evaluation. Common codes used successfully by primary care practices include those for allergic rhinitis, allergic asthma, atopic dermatitis, and related conditions, and quite a few others that don’t automatically bring allergy to mind. The dummy-claim process can be used to confirm any raise eyebrows. You’ll find quite a few of these codes in a quick discussion of how to tell how many of your existing patients already qualify for an allergy test.
4. Consistency Across the Episode
If the test is positive and the patient moves into treatment (e.g. CPT 95165), the same chart should show the decision to treat and the ongoing plan. As discussed above, documenting treatment options given to the patient is good practice for audit defense, even if that option is outside the clinic (referral, or home SLIT, e.g.) Continuity of documentation from survey → test → treatment recommendation is important.