Spring is a great time of year, but it’s also when our offices are flooded with patients symptomatic with ocular allergy. Allergies are an extremely commonplace condition, and nearly half of the patients who walk into your practice will present with signs or symptoms of this common affliction.

Fresh Approaches Pay Off

Allergy is a chronic concern, and clinicians must consider a full-scope approach to its management. This begins with the right diagnosis and, sometimes, new approaches to care.

For example, Doctor’s Rx Allergy Formula: Ocular Allergy Diagnostic System (Bausch + Lomb) allows you to effectively test, in-office, for up to 58 allergens with regional specificity and have results within 15 minutes.¹ This can help you properly identify the specific allergen involved and guide your treatment. It may also help isolate and differentiate allergic manifestations from other common concomitant ocular surface conditions. Currently, 19 states allow its use in optometric scope of practice.

To code for this test, use CPT code 95004, defined as a “percutaneous test(s) with allergenic extracts, immediate type reaction, including test interpretation and report by a physician.” The 2020 CMS National Average Allowable for this code is about $4.32.² When submitting your claim, the number of units is 58 (one unit per allergen), with a billing total of $250.56. However, remember that your charges will be individually determined.

Allergy Coding Refresher 

Coding and compliance requirements for an ocular allergy visit should be in line with other anterior segment conditions. Often, the first presentation of allergy is discovered during the comprehensive exam’s case history, rather than the patient showing up with frank symptoms. 

When you discover signs and symptoms during the routine exam and you choose to initiate or change therapy, only code the exam (and refraction) and bill the encounter to the managed vision care carrier, as the patient didn’t present with signs and symptoms of ocular allergy. If they did, a comprehensive exam would not be the appropriate code to use. 

The subsequent follow-up visit (generally in one week) would meet the requirement of a doctor-directed visit for a specific reason, thus meeting the CC requirements as well as those of medical necessity, which fulfills the requirements for a medical encounter. 

For most cases, the return visit would be an E/M visit code. Most likely the level of the code would be either a 99212 or a 99213 based on meeting the criterion of history, physical exam elements and medical decision making for this visit. Sometimes, a 92002/92012 could be appropriate to use as well, provided that you meet the CPT definition of that code, currently defined as “an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedure as indicated.” 

While some disagree with the application of this definition, it is the current 2020 CPT definition.³ 

There are no CCI edits that affect coding a 920X2 and 95004 on the same date; however, there are issues when performing an E/M code and 95004 on the same date of service. Follow-up evaluations to determine the efficacy of your medical therapy are essential for appropriate follow-up and the typical six-month interval between ocular allergy visits.

The ICD-10 codes typically associated with ocular allergy are H10.001 - H10.019 (acute follicular conjunctivitis), H10.43 - H43.439 (chronic follicular conjunctivitis), H10.44 (vernal conjunctivitis) and H10.45 (other chronic allergic conjunctivitis). 

Ocular allergy is a prevalent condition in the United States, and making your patients aware that you diagnose and treat ocular allergy could be a boon for your practice. You have all the tools and expertise to provide easily accessible, professional care for your patient—and that’s nothing to sneeze at!

Send your coding questions to rocodingconnection@gmail.com.