Does 95004 require prior authorization?

No, 95004 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 95004?

Medicare facility rate: $3.67. Non-facility rate: $3.67. Work RVU: 0.01.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.01

Facility

$3.67

Non-Facility

$3.67

All documentation must be maintained in the patient's medical record and made available to the contractor upon request; every page must be legible and include appropriate patient identification (e.g., complete name, dates of service).
The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
The medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Prior to testing there must be evidence that a history was obtained indicating possible allergy and that attempts were made to narrow the area of investigation so that the minimal necessary skin tests were selected.

Allergy testing is covered when the medical record documents a history indicating the possible presence of allergy and the clinician selected a minimal number of tests/antigens based on patient-specific history and physician examination.
Allergy testing is covered when the medical record documents the test(s) used, the interpretation(s), and objective measurement of reaction size (wheal and erythema in mm) or a standardized in vivo grading system.
Allergy testing for inhalant allergens is covered when medically necessary; evaluation may include up to 90 prick-puncture tests followed by up to 40 intracutaneous tests if prick/puncture results are negative.
Allergy testing for food sensitivity is covered when medically necessary and may require up to 40 percutaneous tests.
Multitest intracutaneous testing of up to 60 tests may be appropriate in lieu of prick-puncture testing for selected patients (for example, young children, older adults, or needle-phobic individuals).
Exceeding the stated testing parameters may be covered when preliminary testing failed and immunotherapy failed to control symptoms, provided documentation supports medical necessity.

L36402 — Allergy Testing

J05

A57473 — Billing and Coding: Allergy Testing

J05

A57531 — Billing and Coding: Allergy Testing

J09

L33261 — Allergy Testing

J09

L33693 — Peripheral Venous Ultrasound

Ask Verity about documentation requirements, denial risks, or coverage in your state.