Billing and Coding: Allergen Immunotherapy

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L37800 Allergen Immunotherapy. Please refer to the LCD for reasonable and necessary requirements. Coding Guidance Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Please refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 200 Allergy Testing and Immunotherapy for instructions on billing for allergy services. Documentation Requirements All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code should describe the service performed. Documentation of any therapeutic expectations, level of antigens, time frame for administration, and any adjustments to the expectation based on local reactions, systemic reactions, missed dosing will need to be very clear in the medical records. Documentation for all references to the therapeutic effective dose in the medical record should be referenced to the maintenance concentrate and should be noted as a volume-to-volume dilution (e.g., 1:100 vol/vol dilution of maintenance concentrate). In the event that allergen immunotherapy is administered to a patient in a home setting, medical record documentation must clearly demonstrate that the benefits of immunotherapy outweigh the risks, include a copy of the patient’s informed consent, and include validation regarding the training and ability of the individual administering the injection to recognize and manage immunotherapy reactions, particularly anaphylaxis.