Documentation Dissection

VITALS:
Sitting RA BP: 106/67(mmHg), Pulse rate: 82(per min), Pulse Ox: 98(%), Height: 5’5”, Weight: 138 lbs 0 oz, BMI: 22.96.

Peak Flow: 375.

ALLERGIES: NKDA

Environment: Hay fever.

This 27-year-old female reported having a history of seasonal allergic rhinitis |1| (spring to early summer) since she was 7 to
8-years-old. But since November, she has been having the symptoms constantly requiring addition of Nasonex and Bepreve to her
treatment |2|. She reported having sinusitis and bronchitis during the peak of spring allergy season. She also reported a history of
intermittent generalized itchy hives/rash for the past year. Each episode would last for 5–14 days at a time |3|.

Past Medical History:

Date: Positive for Hay Fever. Positive for skin rashes. Negative for sensitivity to drugs.

Negative for sensitivity to foods. Negative for asthma. Negative for sensitivity to stings. Negative for Skin Tests. Negative for
Allergy Shots. Negative for Hypertension.

Social History:
She never consumes alcohol. She smokes ¼ pack(s) per day for the last 6-years |4|. She never used recreational drugs. No history of
pneumonia, ear infection or sinusitis.

Surgical History: None.

REVIEW OF SYSTEMS
• Constitutional: Fatigue.
• Head: No headache, sinus pain, swelling of the lips.
• Nasal: Sneezing |5|.
• Eyes: Dry eyes; eyes itch; watery eyes |5|.
• Ear: Tinnitus.
• Throat: Sore throat.
• Neck: No swollen lands, neck pain.
• Cardiovascular: PND.
• Respiratory: No sob, cough, wheezing, feeling congested, hemoptysis or sputum |6|.
• Neuro: No weakness of extremities, headache, giddiness, numbness, tingling, tremor, confusion, memory loss, mood
changes, seizures or trouble walking.
• Skin: No rash; pruritis: hives.
• Psychiatric: No anxiety, depression, hallucination, delusions, aggressive behavior, wandering or crying.
• Hematologic/Lymphatic: No bruises, bleeding or lymphadenopathy.
• Vital Signs: Sitting RA BP: 106/67 mmHg, Pulse Ox: 98%, Pulse rate: 82 per min, Height: 5’5”, Weight: 138 lbs 0 oz and
BMI: 22.96.
• Peak Flow: 375.
• Nose: nasal discharge: Clear, nasal mucosa.

1
Plan:
• Intradermal allergy testing looking for an immediate reaction |7|. Discussed non-reactivity to initial panels of skin tests for
common respiratory allergens. Will discuss lab results on the follow up visit. Discussed the criteria for EpiPen and Benadryl.
Continue to avoid codeine. Continue avoidance of gold metals. Criteria for evaluation reviewed. Deferred evaluation at this
time.

Evaluation:
Using a 28-gauge needle, allergen is injected below the skin surface. We are performing 4 intradermal tests. The areas injected was
observed for 15 minutes. No raised or bumpy places were indicated or shown |8|.

Reactive To: Non-reactive to antigens on intradermal screening multi test.

Assessment:
• Allergic Rhinitis |9|, seasonal.
• Continue with current plan and revisit if conditions worsen.

_____________________________________________________________
|1| Diagnosis supports: Allergic Rhinitis, seasonal.
|2| Current medication.
|3| Recurrent symptoms.
|4| Smoking status.
|5| EENT symptomatic.
|6| Respiratory system is negative.
|7| Support procedure: Intradermal tests with allergenic extracts, immediate type reaction.
|8| Supports procedure: Intradermal tests with allergenic extracts, immediate type reaction, including interpretation and report,
number of tests is 4.
|9| Final diagnosis.

_____________________________________________________________

What are the CPT® and ICD-10-CM codes reported?

CPT® Code: 95024 x 4

ICD-10-CM Code: J30.2

Rationales:
CPT®: Intracutaneous (intradermal) tests with allergenic extracts is documented. In the CPT Index, look for Allergy Tests/
Intradermal/Allergen Extract. You are referred to code range 95024–95028. The physician interpreted the results of the allergy tests
immediately. Code 95024 is the correct code and reported 4 times for each test.

ICD-10-CM: The patient is diagnosed as Allergic Rhinitis that is seasonal. Look in the ICD-10-CM Alphabetic Index for Rhinitis/
Allergic/Seasonal leading to J30.2. Verify in the Tabular List.