Clinical Indicators
Allergy Testing for Allergic Rhinitis

Procedure CPT FUD
Procedure CPT FUD 95004 0
Intradermal testing immediate type reaction 95024 0
Prick Testing Intradermal testing by serial dilution 95027 0
[Skin End Point Titration (SET)]
Intradermal testing delayed reaction 95028 0
Direct nasal mucous membrane test 95065 0
[Medicare allows two components to billing for allergy testing: the code(s) for the allergy test(s) and a code for an E/M service.]
In vitro testing:
Routine venipuncture for collection of specimen(s) 36415 0
IgE 82785 0
Allergen-specific IgE: quantitative or semi-quantitative, each allergen 86003 0
Multi-allergen screen 86005 0

Allergen Immunotherapy: CPT FUD
Professional services for allergen immunotherapy not including provision of allergenic extracts, single injection 95115 0
    two or more injections 95117 0
Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract, single injection 95120 0
    two or more injections 95125 0
Professional services for the supervision and provision of antigens for allergen immunotherapy, single or multiple antigens, single-dose vials (specify number of vials) 95144 0
Professional services for the supervision and provision of antigens for allergen immunotherapy, single or multiple antigens (specify number of doses) 95165 0
Unlisted allergy/clinical immunologic service or procedure 95199 0
[An E/M code may not be used for immunotherapy unless a separate definable service is rendered. Medicare no longer allows payment on 95120 or 95125. Physicians providing both antigen and injection must split bill – 95165 and 95115 or 95117 (95165 may only be charged once per vial). 95144 may only be used in preparing vials for outside injection.]

Indications

1A. History...one or more required (Complaints are perennial or varying with exposure, season, and/or circumstance.)

a) Nasal complaints:
•congestion
•running nose
•itching membranes
•sneezing
•postnasal drip
b) Eye symptoms
c) Asthma (bronchospasm)
d) Sinusitis (chronic or recurrent acute)
e) Pharyngitis
f) Palatal/pharyngeal itching
g) g) Otitis
h) Known inhalants precipitating symptoms
i) Previous allergy treatment
j) Family history of allergies/atopy
k) Aspirin hypersensitivity
l) Headaches
m) Environmental exposure, e.g.:
• pets
• plants
• dust
• smoke

1B. History…one or more generally required prior to instituting immunotherapy and strongly indicated for testing.

a) Failure of environmental controls and/or pharmacotherapeutics.
b) Patient intolerant of environmental controls and/or pharmacotherapeutics.

1C. History…relative contraindications to immunotherapy

a) Concomitant therapy with beta blockers (including eye drops), tricyclic antidepressants, and/or MAO inhibitors.
b) Autoimmune or immunodeficiency disease.
c) Uncontrolled asthma.
d) Induction (not maintenance) immunotherapy during pregnancy.

2A. Physical Examination (elements may be indicated based upon history and initial examination findings)

a) Skin
• eczema
• signs of urticaria
b) Complete intranasal rhinologic evaluation
• signs of sinusitis
• polyps
c) Complete intranasal nasopharyngeal and laryngeal exam
• adenoid hypertrophy
• supraglottic and/or glottic edema
d) Chest auscultation
• wheezes

2B. Allergic Signs (note all that apply)

a) General
• adenoid facies
• restless activity
• grimacing (secondary to itchy mucous membranes)
• allergic salute
• rubbing nose and eyes
• clucking tongue (itchy palate)
b) Eyes
• allergic shiners
• Dennie's lines
• long, silky eyelashes
• conjunctival edema
c) ) Ears
• red auricle
• dermatophytid (id) reaction
• chronic external otitis
• eustachian tube dysfunction
• otitis media with effusion
• chronic otitis media
• dizziness (endolymphatic hydrops)
d) Nose
• supratip crease
• excoriation of nasal meatus
• copious clear, white, or yellow rhinorrhea
• blue boggy or red inflamed mucous membranes
• turbinate hypertrophy
• nasal polyposis
e) Mouth
• mouth breathing
• cheilitis
• high arched palate
f) Pharynx
• cobblestoning
• postnasal drainage
• tonsil and adenoid hypertrophy
g) Neck
• lymphadenopathy

3. Testing (optional, in addition to allergen testing, based upon patients clinical findings)

a) a) Nasal swab and smear for cytology
b) IgA, IgG, and subtypes
c) Thyroid function studies (TSH)
d) Rhinomanometry
e) Acoustic rhinometry
f) Audiogram and impedance
g) Pulmonary function studies
h) Radiologic
• plain films and CT of sinuses
• lateral soft tissue of nasopharynx

Postoperative Observations

1. Immediate reactions—Patient requires medical observation for 20+ minutes following injections/testing
a) Local skin and subcutaneous reactions.
b) Systemic reactions—mild urticaria, nasal congestion, wheezing to anaphylaxis (differentiate from vasovagal response). The rare severe reaction may require immediate treatment with subcutaneous epinephrine or circulatory and/or airway support.
2. Delayed reactions
a) Local reaction—Patient educated to treat with ice pack and possibly topical steroids and inform office for possible return at 24, 48, & 72 hours to record response, especially with molds.
b) Systemic reaction—Patient educated to preload or take antihistamines as needed. The rare, more severe reaction may require an urgent visit and treatment with systemic steroids or other medications. (Either reaction may require adjustment of immunotherapy dosage or, if testing, an adjustment of endpoint, or further evaluation.)

Outcome Review

1. One Month
a) Did clarification of allergen sensitivity by testing/treatment and subsequent avoidance lead to improvement in allergic signs and symptoms?
b) What, if any, complications have resulted from allergy treatment?
2. Three - Twelve Months (may require one year cycle for a seasonal allergen)
a) Did properly administered maintenance immunotherapy lead to an improvement in allergic signs and symptoms?
b) Has immunotherapy allowed a reduction in need for pharmacotherapy and more liberal contact with known allergens?
c) Is the patient experiencing fewer sick days, improved quality of life, and increased productivity?
d) Has there been a net economic benefit from utilizing immunotherapy?
e) What, if any, complications have resulted from allergy testing and treatment?
f) Has escalation of immunotherapy proceeded appropriately?
2. Three - Five Years
a) Immunotherapy gradually withdrawn; observing for recurrence of allergic signs or symptoms.
• if there is no recurrence—immunotherapy discontinued.
• if there is recurrence—immunotherapy continued or reinstituted following reevaluation.

Associated ICD-9 Diagnostic Codes

372.05 Acute atopic conjunctivitis
372.14 Other allergic conjunctivitis
381.04 Acute allergic serous otitis media
381.05 Acute allergic mucoid otitis media
381.06 Acute allergic sanguinous otitis media
381.1 Chronic serous otitis media, simple or unspecified
381.2 Chronic mucoid otitis media, simple or unspecified
381.81 Eustachian tube dysfunction
386.0 Meniere's disease
471.0 Polyp of nasal cavity
472.0 Chronic rhinitis
472.1 Chronic pharyngitis
472.2 Chronic nasopharyngitis
473.0 Chronic sinusitis, maxillary
473.1 Chronic sinusitis, frontal
473.2 Chronic sinusitis, ethmoidal
473.4 Chronic sinusitis, sphenoidal
473.8 Chronic pansinusitis
473.9 Unspecified sinusitis (chronic)
474.0 Chronic tonsillitis and adenoiditis
474.1 Hypertrophy of tonsils and adenoids
476.0 Chronic laryngitis
476.1 Chronic laryngotracheitis
477.0 Allergic rhinitis, due to pollen
477.8 Allergic rhinitis, due to other allergen
477.9 Allergic rhinitis, cause unspecified
478.0 Hypertrophy of nasal turbinates
478.1 Other diseases of nasal cavity and sinuses (nasal obstruction)
478.25 Edema of pharynx or nasapharynx
478.6 Edema of larynx
478.8 Upper respiratory tract hypersensitivity reaction, site unspecified
493.0 Extrinsic asthma
708.0 Allergic urticaria
786.2 Cough

Additional Information
Assistant Surgeon -- No
Supply Charges -- 99070 (i.e. Emla cream)

Anesthesia Code(s)
01240, 01700, 99141, 99142

Patient Information
Inhalant allergies can cause a multitude of symptoms involving any of the body's systems but mainly the upper respiratory tract. Persistent and recurrent "colds," "hay fever," "catarrh," and "sinus" are typical examples of allergic symptoms. Inhalant allergies man be triggered by any substance that can be inhaled and absorbed by the body. The primary problem inhalants are pollens, molds, and environments, including dust, dander, and mites.

Allergy treatment is based upon three general modalities: environmental control or avoidance of offending substances, medications, and immunotherapy (allergy shots). Patients may require one, two, or three modalities for success. Treatment is generally begun with avoidance—progresses through various medications and, if these fail or are not satisfactory for the patient, immunotherapy is instituted.

The type and length of therapy required is quite variable and depends on many factors. For example, a patient may experience dramatic symptomatic improvement simply by careful environmental control, such as removing a cat from the household. Antigen avoidance becomes less important as immunotherapy is established, but overwhelming exposure may produce symptoms even after symptom control with immunotherapy. Similarly, the need for allergy medication may decrease or dissappear as immunotherapy is instituted. A typical course of immunotherapy encompasses three to five years, although some patients may require immunotherapy for an indefinite period of time.

Important Notice

The Clinical Indicators for Otolaryngology--Head and Neck Surgery are guidelines only. In no sense do they represent a standard of care. The applicability of an indicator for a procedure, and/or of the process or outcome criteria, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these guidelines will not ensure successful treatment in every situation. The American Academy of Otolaryngology-Head and Neck Surgery, Inc. emphasizes that these clinical indicators should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results.

© 2000 American Academy of Otolaryngology-Head and Neck Surgery. One Prince Street, Alexandria, VA 22314.