Oral immunotherapy (OIT) for food has been considered investigational and to date there has not been an FDA approved product for desensitization to foods. The Allergenic Products Advisory Committee of the U.S. Food and Drug Administration (FDA) recently voted to support approval of a standardized OIT product for peanut allergy, Palforzia1, 2. Final approval is pending, but could occur as soon as late 2019 or early 2020.
Optimal Coding for Current OIT Services
While there are no specific codes for reporting OIT services, the AAAAI and ACAAI have considered various options for optimal reporting of this therapy to health plans and payers. The result of this joint deliberation is the following recommendation for coding OIT services:
Initial OIT Visit
Because the initial escalation visit is essentially a challenge to determine the level of sensitivity, it is appropriate to use the ingestion challenge codes:
• CPT® 95076: Ingestion challenge test (sequential and incremental ingestion of test items e.g. food, drug or other substance); initial 120 minutes of testing; and
• CPT® 95079: each additional 60 minutes of testing (List separately in addition to code for primary procedure).
The time, which should be documented, is the number of minutes the patient is in the office beginning with initiation of the procedure and not physician face-to-face time. The codes don't require a specific number of minutes of physician face-to-face time although 30 minutes was used for valuation purposes. However, the physician must be in office and it is important to document that.
This is most appropriately coded using an E/M code plus prolonged service code(s) if needed. The prolonged service codes may be used when the time exceeds the typical time for the applicable E/M service by over 30 minutes.
• CPT® Established Patient E/M Code (select appropriate E/M level)
• CPT® 99354: Prolonged evaluation and management service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management)
• CPT® 99355: each additional 30 minutes (List separately in addition to code for prolonged service).
Allergy/immunology practices should follow health plan and payer policies for coverage and reimbursement of OIT services, where available, even though they may differ from the above.
Beginning in 2021, Medicare intends to adopt major changes to the E/M and prolonged service codes that will impact the above information. We will update you as soon as those changes have been finalized. Should FDA approve OIT products, the AAAAI and ACAAI will consider options for establishing new and/or revised codes for this therapy. See the AAAAI and ACAAI websites for additional information.
1 Previously known as AR101