Practices that perform allergy testing have a hard deadline coming up. A uniform allergy diagnostic testing policy for Medicare Part B patients takes effect across 38 states starting September 27, and the rules apply to any service performed on or after that date — including a patient’s very first visit, even if that appointment was booked months in advance. Practices should treat the notice period as prep time, not a grace period.
Who Issued the Policy and When It Applies
Five Medicare administrative contractors (MACs) — CGS Administrators, Palmetto GBA, Noridian, WPS GHA, and Wellpoint Federal (formerly National Government Services) — issued this new uniform local coverage determination (LCD). Most of these MACs go live September 27; CGS Administrators is the outlier, with an October 4 effective date.
The policy comes with a companion billing and coding article and touches several core allergy testing codes: percutaneous testing with allergenic extracts to provoke an immediate reaction (CPT 95004), intracutaneous or intradermal testing for the same purpose (CPT 95024), and patch testing used to identify contact allergens behind dermatitis (CPT 95044). Coders who also handle the immunotherapy side of an allergy practice will want these alongside their existing reference points for allergen extract and injection codes and antigen preparation billing, since testing and treatment charts often land on the same coder’s desk.
According to J. Allen Meadows, MD, FACAAI, executive director of advocacy and government affairs at the American College of Allergy, Asthma & Immunology, the MACs worked closely with specialists throughout the process and made real changes based on that input — expanding the number of allowed patch tests and broadening the covered diagnosis list in the final version. Meadows described himself as pleased with both the process and the outcome. That said, this summary only hits the highlights; every provider is still responsible for reading the full LCD and its associated documents, including the billing and coding article and the formal response to public comments.
Confirm Provider and Staff Readiness First
The LCD doesn’t restrict testing to physicians or advanced practice practitioners enrolled specifically as allergy specialists. But anyone performing tests involving immediate reactions (like skin scratch tests) or delayed reactions (like challenge tests) must have the knowledge, training, and clinical judgment to appropriately select, perform, and interpret the results. Providers also need to be able to recognize and manage a serious allergic reaction, including anaphylaxis — and if clinical staff are the ones administering the test, they must work under the direct supervision of someone with that training. Resuscitative equipment has to be on hand and ready during testing, full stop.
Get the LCD’s Terminology in Front of Your Team
Part of preparing your staff is making sure everyone is using the same definitions the MAC is using. For the most commonly reported IgE tests:
- Percutaneous testing is used for suspected IgE-mediated reactions to inhalants, Hymenoptera venom (bee or fire ant stings), foods, certain drugs, and workplace allergens.
- Intracutaneous or intradermal testing (IDT) comes into play when percutaneous results are negative but clinical suspicion remains high. Notably, the LCD does not recommend IDT for food or latex allergy, given the risk of a severe systemic reaction.
- Skin patch testing is used to diagnose allergic contact dermatitis triggered by substances like detergents, oils, metals, chemicals, or food.
Medical Necessity and Documentation Are Where Claims Live or Die
Coders and clinicians both need a clear picture of what counts as medically necessary under this LCD, because the documentation for every encounter has to support the diagnosis codes, procedure codes, and units of service being billed. It’s worth comparing your current chart templates against the new policy now and flagging any gaps to providers before the effective date.
Under the LCD, medical necessity starts before a single test is administered — it requires a documented comprehensive medical and immunologic history and physical exam showing the patient’s symptoms are consistent with an allergic reaction, plus documentation of exposure to the suspected allergen(s). The chart also needs to show the provider’s reasoning for narrowing down the allergen list, so that testing is limited to the minimum number of skin tests needed to reach a diagnosis. In other words, the antigens selected for testing should trace directly back to the findings in the history and exam.
Documentation of the test itself has to be just as thorough. A skin scratch test chart, for instance, needs the provider’s interpretation along with measurements of both the wheal (in millimeters) and the erythema response, or an equivalent standardized in vivo grading system where applicable.
It’s equally important to flag what’s not medically necessary under the new policy, including:
- Routine, repeat testing — unless the chart documents why it was necessary, such as new allergen exposure, new symptoms, or a treatment plan that isn’t working.
- A lab test performed in addition to skin testing for the same antigen — except in cases of suspected latex sensitivity, Hymenoptera, or nut/peanut sensitivity.
Know the Utilization Limits Before You Bill
To head off unexpected denials, review the LCD’s limitations section carefully alongside current guidance from relevant professional associations. The overall testing volume shouldn’t exceed generally accepted standards set by those associations, but the LCD also sets specific numeric caps: up to 70 percutaneous tests for inhalant allergies, 40 percutaneous tests per patient per day for other indications, and a ceiling of 90 patch tests across all appropriate antigens.
The percutaneous and patch test limits line up with the existing medically unlikely edits (MUEs) for those codes. The skin scratch test code, 95004, is the exception — its MUE is set at 80. In theory, the MACs will apply an edit based on whether the claim indicates inhalant allergy testing, but coders should still watch closely for improper denials or overpayments tied to this code and be ready to appeal or correct claims as needed. If your practice is also billing an E/M visit alongside testing on the same date, this is a good moment to revisit modifier 25 documentation requirements to make sure that pairing holds up under audit.
Bottom Line for Coders
This LCD folds a lot of clinical judgment into what used to be more mechanical code selection — the emphasis on documented reasoning behind allergen selection, test-by-test interpretation, and specific utilization caps means coders will need to read allergy charts more closely, not just pull codes off an order sheet. Build in time now to compare your practice’s current templates against these requirements, and make sure billing staff understand where the new numeric limits sit relative to existing MUEs, so nothing slips through when the effective date hits.
