New guidelines for allergen immunotherapy documentation have been issued by the American College of Allergy, Asthma & Immunology (ACAAI), the American Academy of Allergy, Asthma & Immunology (AAAAI), and the American Academy of Otolaryngic Allergy (AAOA). These recommendations aim to assist insurance companies in determining appropriate documentation requirements for allergen immunotherapy claims. The guidance is detailed in a paper published in Annals of Allergy, Asthma and Immunology.
"Burdensome and unreasonable requests for documentation regarding these services threaten the ability of allergists/immunologists and otolaryngologists to administer these therapies," said Dr. J. Allen Meadows, ACAAI Executive Director of Advocacy and Government Affairs. "They also hinder the ability of patients with allergic conditions to obtain relief."
Allergen immunotherapy, commonly administered as allergy shots or subcutaneous immunotherapy (SCIT), is recognized as an effective treatment that modifies the immune system's response to allergens. This can reduce allergic reactions and prevent new allergies or asthma from developing.
The new guidelines focus on making the review process for claims under CPT Codes 95165, 95115, and 95117 more efficient and less burdensome. The procedures covered by these codes are deemed medically necessary for patients with conditions such as allergic rhinitis, asthma, or atopic dermatitis.
"In recent years, payers have increasingly demanded multiple, detailed documentation that is both highly burdensome to the physician and generally unnecessary," states the paper. Such demands have led to delays in payment or non-payment for legitimate procedures.
The guidance outlines what constitutes reasonable requests for documentation when processing claims related to allergen immunotherapy services:
- Identification of the physician who established the treatment plan.
- Patient identity along with a brief description of clinical indications.
- A summary of the treatment plan including its formulation date.
- Details on patient response to therapy during routine visits.
For CPT Codes 95115 or 95117 specifically:
- Date and details of injection including patient information.
- Dose specifics such as volume, dilution, number of injections.
- Injection site details.
- Initials or signature (actual/electronic) of administering personnel.
Certain documentation requirements are deemed unnecessary:
- Vial expiration dates
- Full dosing schedules
- Subcutaneous administration specifications
- Ordering healthcare professional's signature
- Credentials of administering personnel
- Previous injection history
- Multiple audit requests
Dr. Meadows emphasized that excessive demands from insurers not only burden physicians but may also impact patient care: "Patients who suffer from allergic diseases such as allergic rhinitis, asthma and atopic dermatitis rely on consistent delivery of allergen immunotherapy to keep their symptoms under control. When they can’t get it, their quality of life is compromised."
