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Three tips are all you need to correctly bill allergen immunotherapy, single or multiple antigens. Allergy services, such as those reported with CPT® 95165 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single or multiple antigens (specify number of doses), remain on the radar of third-party payer investigation units […]
The post CPT® 95165 Coding Conundrums appeared first on AAPC Knowledge Center.
Three credible sources give three different answers, and only one is right. The definition for billing units of allergy serum preparation for patients was recently challenged by a colleague of mine who works in the allergy space. Are their limitations on diluted antigens when counting units for CPT 95165 Professional services for the supervision of […]
The post How Many Units of 95165 Can You Bill, Really? appeared first on AAPC Knowledge Center.
Preparation and provision of antigens for allergen immunotherapy is performed once the patient has gone through allergy testing and it has been determined that the patient has allergies to one or more substances. The antigens for allergen immunotherapy are then prepared using the results of the allergy testing. The goal of the immunotherapy is to desensitize the patient to the elements to which the patient is allergic. The desensitization process involves administering very diluted antigens via injection, gradually building up to a maintenance dose over time.
Dosage Preparation Factors into Payment:
The doses leading to the maintenance dose are all diluted by a significant amount of sterile saline. Dosage vials are initially prepared with maintenance doses of the antigens. A small amount of the maintenance dilution is placed into another vial. That vial is then filled to capacity (e.g., 10 cc) with diluent. This vial will have a different color top from the maintenance vial. A small amount of the diluted antigen from the second vial is withdrawn and placed in a third vial, which is also filled to capacity with diluent.
There are examples where some allergy preparations will continue this progression until seven vials, or 70 cc, of maintenance and diluted antigens are prepared.
The description in the CPT® code that describes this process says to “specify number of doses.” This means that you need to know how much antigen and diluent is drawn up into the syringe to make up a “dose.” You also need to know what the payer defines as a dose, as they may override the actual dose that is administered for a “reimbursable dose” definition specific to that payer.
Medicare Part B Has Its Own Rules:
Medicare Part B has a very specific and restrictive definition of a “dose” for CPT 95165. No other payer (that I know of) has this same definition, stating in the 2001 Medicare Physician Fee Schedule final rule that a “dose” is 1 cc aliquot of maintenance antigen. Medicare Part B will not pay for diluent beyond what is needed to create the maintenance antigen.
In the above example, where the three vials were created, two vials diluted from a maintenance vial, giving 30 cc of antigen, Medicare Part B would only pay for the original vial of non-diluted maintenance antigen — 10 units for the 10 cc in that vial.
Even if the patient is receiving 0.5 cc shots, meaning each vial provides 20 allergy shots, Medicare Part B only recognizes 1 cc doses. As a result, only 10 units may be billed to Medicare Part B. In the example above, where allergy operations make up seven vials, or 70 cc of antigen, you can only bill Medicare Part B for 10 units for the one maintenance dose vial.
Consider Unlikely Scenarios (MUE):
Medicare Part B has medically unlikely edit (MUE) of any amount above 30 units to recognize that different vials of maintenance antigens can be made up for antigens that cannot be mixed together and must be kept separate. A patient who was given 30 units of 95165 received three shots. A patient who received 20 units of 95165 was given two shots.
DO NOT bill Medicare Part B for 20 or 30 units of diluted vials. The 20 or 30 units should only be billed to Medicare Part B if the patient has allergies such that the antigens cannot be mixed and must be kept separate in two vials (20 units) or three vials (30 units).
Source: Guidlines for CPT 95165
The professional service of preparation and provision of antigens for allergen immunotherapy — reported using CPT® 95165 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) — is often misunderstood and incorrectly coded and billed to third-party payers. This misunderstanding causes a […]
The post Billing 95165 Is Nothing to Sneeze At appeared first on AAPC Knowledge Center.
H10.11 Acute atopic conjunctivitis, right eye
H10.12 Acute atopic conjunctivitis, left eye
H10.13 Acute atopic conjunctivitis, bilateral
H10.44 Vernal conjunctivitis
H10.45 Other chronic allergic conjunctivitis
J30.1 Allergic rhinitis due to pollen
J30.2 Other seasonal allergic rhinitis
J30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander
J30.89 Other allergic rhinitis
J45.20 Mild intermittent asthma, uncomplicated
J45.30 Mild persistent asthma, uncomplicated
J45.40 Moderate persistent asthma, uncomplicated
J45.50 Severe persistent asthma, uncomplicated
T63.421A Toxic effect of venom of ants, accidental (unintentional), initial encounter
T63.421D Toxic effect of venom of ants, accidental (unintentional), subsequent encounter
T63.421S Toxic effect of venom of ants, accidental (unintentional), sequela
T63.422A Toxic effect of venom of ants, intentional self-harm, initial encounter
T63.422D Toxic effect of venom of ants, intentional self-harm, subsequent encounter
T63.422S Toxic effect of venom of ants, intentional self-harm, sequela
T63.423A Toxic effect of venom of ants, assault, initial encounter
T63.423D Toxic effect of venom of ants, assault, subsequent encounter
T63.423S Toxic effect of venom of ants, assault, sequela
T63.424A Toxic effect of venom of ants, undetermined, initial encounter
T63.424D Toxic effect of venom of ants, undetermined, subsequent encounter
T63.424S Toxic effect of venom of ants, undetermined, sequela
T63.441A Toxic effect of venom of bees, accidental (unintentional), initial encounter
T63.441D Toxic effect of venom of bees, accidental (unintentional), subsequent encounter
T63.441S Toxic effect of venom of bees, accidental (unintentional), sequela
T63.442A Toxic effect of venom of bees, intentional self-harm, initial encounter
T63.442D Toxic effect of venom of bees, intentional self-harm, subsequent encounter
T63.442S Toxic effect of venom of bees, intentional self-harm, sequela
T63.443A Toxic effect of venom of bees, assault, initial encounter
T63.443D Toxic effect of venom of bees, assault, subsequent encounter
T63.443S Toxic effect of venom of bees, assault, sequela
T63.444A Toxic effect of venom of bees, undetermined, initial encounter
T63.444D Toxic effect of venom of bees, undetermined, subsequent encounter
T63.444S Toxic effect of venom of bees, undetermined, sequela
T63.451A Toxic effect of venom of hornets, accidental (unintentional), initial encounter
T63.451D Toxic effect of venom of hornets, accidental (unintentional), subsequent encounter
T63.451S Toxic effect of venom of hornets, accidental (unintentional), sequela
T63.452A Toxic effect of venom of hornets, intentional self-harm, initial encounter
T63.452D Toxic effect of venom of hornets, intentional self-harm, subsequent encounter
T63.452S Toxic effect of venom of hornets, intentional self-harm, sequela
T63.453A Toxic effect of venom of hornets, assault, initial encounter
T63.453D Toxic effect of venom of hornets, assault, subsequent encounter
T63.453S Toxic effect of venom of hornets, assault, sequela
T63.454A Toxic effect of venom of hornets, undetermined, initial encounter
T63.454D Toxic effect of venom of hornets, undetermined, subsequent encounter
T63.454S Toxic effect of venom of hornets, undetermined, sequela
T63.461A Toxic effect of venom of wasps, accidental (unintentional), initial encounter
T63.461D Toxic effect of venom of wasps, accidental (unintentional), subsequent encounter
T63.461S Toxic effect of venom of wasps, accidental (unintentional), sequela
T63.462A Toxic effect of venom of wasps, intentional self-harm, initial encounter
T63.462D Toxic effect of venom of wasps, intentional self-harm, subsequent encounter
T63.462S Toxic effect of venom of wasps, intentional self-harm, sequela
T63.463A Toxic effect of venom of wasps, assault, initial encounter
T63.463D Toxic effect of venom of wasps, assault, subsequent encounter
T63.463S Toxic effect of venom of wasps, assault, sequela
T63.464A Toxic effect of venom of wasps, undetermined, initial encounter
T63.464D Toxic effect of venom of wasps, undetermined, subsequent encounter
T63.464S Toxic effect of venom of wasps, undetermined, sequela
See also: Guidelines for Allergy Immunotherapy
– 3 vials with each 2.75 cc (10 doses each)
– 1 vial with 5.75 cc (16 doses)
The administration will be weekly over 46 weeks. I read a lot from other coders that they charge by the doses no matter the total cc, in this case 95165 x 46.
Per Medicare guidelines a dose is defined as one (1) cc. Please see below:
Allergen Immunotherapy (Medicare excerpts)
Billing Guidelines:
CPT procedure code 95165 is used to report multiple dose vials of non-venom antigens. Effective January
1, 2001, for CPT code 95165, a dose is now defined as a one- (1) cc aliquot from a single multidose vial.
When billing code 95165, providers should report the number of units representing the number of 1 cc
doses being prepared.
In my case that would mean 95165 x 14 cc total.
Doesn’t this guideline apply to commercial insurances as well? There is a big difference between 14 vs 46 units.