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2025 CPT code 95199

Unlisted allergy/clinical immunologic service or procedure.

CPT guidelines for unlisted procedures must be strictly followed.Detailed documentation is paramount for payment.Consider payer-specific guidelines, which may vary regarding reimbursement for 95199.

Modifiers may be applicable depending on the specific circumstances and the additional services performed (e.g., modifier 25 if a significant, separately identifiable E/M service is performed).

Medical necessity is established by documenting that the procedure performed was necessary to diagnose or treat the patient's condition, that no other CPT codes appropriately describe the procedure, and that the procedure was performed according to established medical standards.

The physician or qualified healthcare professional performs a unique allergy or immunology procedure not covered by existing CPT codes.This includes the complete process, from assessment and planning to execution and follow-up.

IMPORTANT:Use only when no other specific CPT code applies.Consider using more specific codes like 95115-95170 for allergen immunotherapy if applicable.If Category III codes exist for the service, those should be used instead of 95199.If using 95199, detailed documentation of the procedure, rationale for using an unlisted code, and comparison to similar coded procedures must be provided to the payer.

In simple words: This code is for allergy or immune system tests or treatments that don't have their own specific code.If your doctor does something unusual, they use this code and explain it fully to your insurance company to get paid.

This CPT code is used to report allergy or immunology services or procedures that do not have a specific CPT code.It should only be used when no other appropriate code exists and requires detailed documentation supporting medical necessity and the distinct nature of the service performed, justifying its unlisted status.The service must be clearly differentiated from other established CPT codes to avoid denial of payment.

Example 1: A patient presents with a severe, unusual allergic reaction to a novel medication not previously documented in medical literature. The physician performs extensive testing and develops a unique desensitization protocol, billing 95199 to account for the customized approach., A patient experiences an allergic reaction to a combination of environmental allergens that is too complex for standard allergy testing.The physician uses 95199 to bill for a specialized test developed to isolate the specific allergens causing the reaction., A patient needs a customized immunotherapy regimen.The physician prepares a specific allergenic extract not commercially available, using this code to bill for the preparation and administration of the unique solution.

Detailed description of the performed procedure, including rationale, materials, techniques, and time spent. Justification for using 95199 instead of a specific code. Comparison to similar procedures with their respective CPT codes.Complete patient history, including allergy testing results and relevant medical history.Operative notes or procedural records.Patient's response to the procedure.Copies of any unique materials used.

** Due to the nature of this unlisted code, thorough and precise documentation is essential to prevent claim denials.Pre-authorization or verification of benefits with the payer before performing the service is strongly recommended.Payment is highly dependent on the payer’s interpretation of the documentation and their internal policies.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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iFrame™ AI's knowledge is aligned with and limited to the materials uploaded by users and should not be interpreted as medical, legal, or any other form of advice by iFrame™.