Allergy, Immunology, Asthma, Pulmonology Billing


Allergy and Immunology

Billing for Allergy services performed by a physician specializing in Allergy and Immunology (Allergist) can be very challenging. As skin testing is used as the primary tool to determine treatment for the condition, billing for this component requires sound experience. Knowing when to use modifiers together with the proper number of skin tests to be billed and how the specific insurance plan responds needs to be determined thru experience or at the beginning of treatment. As the number of testing “pricks” increase, in terms of quantity, the amounts billed must be clearly defined and documented. Many insurance companies have “ceilings” or quantity limits for a specific day of treatment thus facilitating the need for return office visits. Failure by the biller to adequately identify the proper amount of testing can lead to denials by the insurance carrier.

Food sensitivity testing, completely different than prick testing, requires the understanding of billing protocols for prolonged services and for reporting the monitoring of patient’s vitals (blood pressure, pulse rate and respiration) during this documented test.

Many patients continue to see their Allergist for many years thus creating a strong bond and more dependency on the practice to obtain maximum benefits on behalf of the patient when submitting an insurance claim.

The treatments (Allergen Immunotherapy—allergy shots), being patient specific, can have serum mixed for up to one (1) year of usage. This may also include the desensitizing process in order to establish a maintenance dosage of antigen for each individual patient. Once again billing experience is paramount in knowing how to determine if the insurance will reimburse for the pre-mixed antigens or batch billing at the time of mixing. Billing for administering the antigens, either single or multiple shots, and desensitization also requires knowledge of this specialty.

Nebulizer treatments, as done in the office, or portable Nebulizer’s that the patient may purchase (which the office will submit for insurance reimbursement) also have unique billing requirements which require modifiers.

Determining and collecting the proper copays, deductible, and coinsurance at the time of service is another function that MEDX can assist the front office staff. Our ability to successfully work with the medical practice to ensure proper coding, documentation, and billing protocol for maximum reimbursement demonstrates the MEDX expertise.

Asthma and Pulmonolgy

When the Asthmatic patient visits the physician specialist (Pulmonologist) the need for additional treatments/procedures may also be necessary at that visit. As services such as Bronchospasm Evaluation, Respiratory flow volume loop, Pulmonary stress testing, Chest wall manipulation, to name a few, are performed, the use of proper billing codes and modifiers become crucial to avoid denials. Many insurance carriers may “bundle” or deny parts of the total services rendered during the specific visit if not submitted correctly. Too often the biller has no experience or expertise with the technical billing demands for proper reimbursement of this speciality.

When dealing with pediatric practices that may also have a pulmonary specialist within the group the problems can be amplified since the patients PCP may be a member of the same group.

Authorizations for pulmonary evaluation and/or treatment is generally necessary when dealing with an HMO/IPA. Proper claim submission with authorization numbers should always be used when available. Even services that are authorized can be denied or bundled by the HMO/IPA.