Posted in In The Know Series, My services, Training, Updates

Empire NYSHIP Plans and member cost-sharing for diagnostic allergy and asthma testing: year 2020 and beyond

This post is for Allergy & Asthma providers that accept Empire NYSHIP (TPA UHC) patients and perform diagnostic asthma/allergy testing in the office setting (POS 11).

Commonly used CPT codes in Office Setting (w/ short description)

1. 95004- skin prick allergy testing

2. 95024- intradermal allergy testing

3. 95044- patch allergy testing

4.95018- Medication (Penicillin) allergy testing

5. 94200- Peak flow

6. 95012- NIOX or FENO

Member cost-sharing/patient co-pays for year 2020 and beyond:

Most of the Empire NYSHIP plans (there are various types), have updated their co-pay to $25 per office visit (specialist) Please click here to visit my post on the updated Empire NYSHIP co-pays.

However, as recent as last year, the Empire NYSHIP plans also started to add, an extra $25 member cost-sharing fee, to the above mentioned CPT codes. In order for your office not to leave this uncollected revenue on the table, please make sure to inform your front office staff of this change!  

Now  let’s take a look at 2 (TWO) examples.

Ex. 1. Patient comes in for the first time and has the environmental skin prick testing done the same day. The billing would be:  99204 25 with 95004X40 -the total patient financial responsibility would be $50: $25 for OV and $25 for testing.

Ex. 2. Patient with DX of Allergic Asthma (J45.30) is coming in for a follow up visit. The billing would be: 99213 25 with 94200 59 and 95012 59. In this instance the second co-pay would be applied to 94200 and 95012 would be paid. So, the patient will still pay only $50 co-pay.

Now, If you have any more questions about this post, Empire NYSHIP patients cost-sharing or something else, please go on my (SERVICES) page and contact me for a free 30-min Evaluation ($250 Value).

Posted in Insurance, My services, Payers and CPT reinbursement, Training

Empire Plan(UHC) and CPT code 95004

This is a third installment in my Payers and CPT codes series.

In this installment we will look at the payer Empire Plan (Light Blue card). For this payer UHC is the third party administrator and handles all administrative duties.

Now I am sure you know that when you see a patient with this type of insurance, there is a $20 copay for the office visit. However, not many providers know that there is also another fee for another service, if that services is performed on the same date.

The following will help you to collect the correct amount of patient responsibility from the patient, on the day of services are rendered, and not wait until the claim is processed, which could be 14 or more days; thus increasing your cash flow and reduce your outstanding A/Rs.

In this scenario, you have a new patient coming in to see an allergist for an unspecified allergic reaction:

Code 1: 99204 or 99203 – NEW PATIENT Patient responsibility- $20


Ok, now the patient also has not taken any antihistamines in at least the last week and would like to do prick allergy testing , cpt code 2: 95004.

According to UHC, the third party administrator for this plan, 95004- is considered a separate (diagnostice) procedure if performed on the same day, therefore there is also an additional co payment of $20 that is attributed to the patient responsibility.

So, lets review- new patient code 99204 or 99203 w/25 ,a code 95004 for skin testing – patient copay $20 for the office visit and $20 for the prick allergy testing.

Since I already know this in advance, I have a separate form that I give to patients when they arrive to the office, BEFORE performing the procedure.

Giving the patients the option of either doing the prick testing or sending them for blood work (no additional fee when they on that day, if dont in the outside lab)

If you have any other further questions, please feel free to contact me via email or phone, listed on my about me page, or via my LINKEDIN account or my Facebook page.

Until next time!