Reimbursement


Accurate coding and documentation is essential for reimbursement for medical services. Coding is intended to transform a physician's verbal descriptions of diseases and procedures into standardized numeric designations, facilitating patient care documentation, and billing.

Currently, the three major coding systems include:

These systems are used by both government and private health care payers for health care reimbursement. They can change frequently and vary by geographic location and payer. Always refer to current versions of these coding guides.

In addition to understanding these coding systems, physicians and staff should know the policies and procedures for their primary payers or contracted health plans. This includes information about patient coverage, anticipated and contracted reimbursement rates, definition of complete claims, claims appeal processes, as well as appropriate contact numbers, email and addresses.

General Notes

To optimize practice reimbursement, it is important to code patch testing correctly, provide accurate and sufficient documentation, and bill for all services provided. The level of service reported and billed for all patient visits must be justified by medical necessity and supported by appropriate documentation in the patient's medical record. Because coding practices are complex and change frequently, it can be valuable for physicians to implement one or more of the following in their practice:

  • Regular staff instruction about proper coding, documentation and billing procedures.
  • Standardized coding and practice management software that is well documented, such as Ellzey Coding Solutions, Inc.
  • A reference sheet for commonly used allergy and dermatology-based codes for your practice, including CPT 95044 and ICD-10-CM 692 examples.
  • The use of an independent, audited coding and billing agency familiar with local federal and private payers.

In today's health care, accurate coding is considered the ethical and legal responsibility of the physician and their practice. Recurring procedural errors can lead to reimbursement delays, unpaid claims, loss of revenue, and even disciplinary action and legal sanctions.

Frequently Asked Questions

How long until I get reimbursed or denied?
Typically, approved claims get paid in 5-7 business days. Alternatively, denied claims often take 30 or more days.

Should I bill for every visit, and does my patient pay a copay for every visit?
Depending on your patient's insurance carrier & policy, a co-pay for each visit may be applicable.

How do I know how many Units to bill?
One allergen = one unit. You should code for every allergen tested. For example, if you test the patient to 36 allergens, you should bill for 36 units.

Does Medicare have different requirements than Commercial Insurance?
Medicare requires two lines when billing more than 90 units. You should also use modifier 59 on the second line when billing Medicare. Typically, most commercial insurance companies do not require a modifier or second line.

Is there a cap on how many allergens I can test/bill per visit?
Even the same insurance carrier may have differences in coverages. The best way to avoid a denial is to get preauthorization.

Reimbursement rates and policies vary state by state and company by company.


Disclaimer: The brief information included here about coding and reimbursement is for educational purposes only. It should not replace current Medicare or specific payer policies, state or federal regulations, medico-legal practice guidelines, or consultation with coding experts or attorneys. Users should always consult payers for final guidance and about changes in coding and reimbursement practices. SmartPractice® and SmartPractice Denmark® assume no liability from the use of this manual.

For more details on patch test reimbursement, contact our customer service department at 1-800-878-3837.