| 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.
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