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95004

Carlos Posted Thu 27th of September, 2018 13:11:29 PM
Do you have any documentation showing that Pulmonologists are allowed to bill for Allergy Test CPT 95004? We received a denial from Aetna Betterhealth and the reason given was that provider specialty may not bill this service. we have billed for this service to other insurances and we got paid. In fact for Molina no authorization is required if this service is given by Allergists and Pulmonologists
SuperCoder Answered Fri 28th of September, 2018 03:11:36 AM

Hi Carlos,

 

Thanks for your question. Please note that there is no restriction for pulmonologists to bill code 95004. But to bill allergy testing (e.g. code 95004) to Aetna Betterhealth, you need to have prior authorization from the payer. For more information please read chapter 5, page 31 in the below link:

https://www.aetnabetterhealth.com/newjersey/assets/pdf/providers/ProviderManual-NJ.pdf

 

Moreover, you need to map with the CPT code, the appropriate diagnosis codes which are listed by the payer, please see section D and E in the below link:

https://www.aetnabetterhealth.com/louisiana/assets/pdf/providers/policies/LA-Policy Allergy Testing -Percutaneous and Intracutaneous.pdf

 

Please feel free to write if you have any question.

 

Thanks

Carlos Posted Fri 28th of September, 2018 17:23:46 PM
Thank you for your reply. We do have an authorization on file from the insurance for this CPT code. I forgot to mention we are located in Florida. When I requested documentation about this I was thinking more about any article from any Pulmonary specialty source saying that allergy testing is within the scope of practice of a pulmonologist because the denial reason is not an authorization issue, the reason for the denial is the following: This provider type/provider specialty may not bill this service.
SuperCoder Answered Mon 01st of October, 2018 08:48:59 AM

We appreciate your patience, our experts are working on this query.

Thanks.

SuperCoder Answered Wed 03rd of October, 2018 08:13:44 AM
Hi Carlos,
 
Thanks for your patience.
 
Please be informed that policy of Aetna BetterHealth do not specify anything about the provider type allowable for the allergy testing.
 
It may be possible that they are considering it experimental depending on the medical necessity (diagnosis) or indication for the testing per the Aetna policy.
 
There seems to be some payer specific guideline, which is restricting the reimbursement of the billed services by the specialty physician (i.e. pulmonologist).
 
You need to call the Aetna Betterhealth representative to ask the reason behind denial of CPT code 95004 when billed by a pulmonologist.
 
Thanks.

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