CPT® 95165 Coding Conundrums


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 because auditors continue to find medical practices that incorrectly code and bill for these services. Although there has been no change in the Medicare policy which has been in place for years, there seems to still be confusion as to the rules for billing allergen immunotherapy. To complicate matters, many insurance companies now limit the number of units/doses of antigens they allow for 95165 at one time.

Medical billing for allergen immunotherapy is highly complex and requires well-educated medical coders to ensure accurate and timely reimbursement. Here’s what you need to know to get 95165 paid.

Four Components to Allergy Services

Allergies are very common in children and adults. It’s estimated that one in five people in the United States has allergic rhinitis, also known as hay fever. This condition is caused by an allergic reaction to substances in the environment such as trees, grass, and weed pollens, dust mites, pet dander, and/or molds. It is the sixth leading cause of chronic illness in the United States, with an annual healthcare cost of more than $18 billion.

There are four key components of allergy services that you should consider when billing CPT® 95165:

  1. Allergy testing,
  2. Preparation,
  3. Provision of antigens for allergen immunotherapy, and
  4. Administration of allergy shots.

Skin testing is the gold standard and is used with medical history to find out exactly what a patient is allergic to. These tests are not invasive and, for most allergens, tend to produce quick, reliable results to identify trigger factors for allergy symptoms such as runny nose, sneezing, and itchy, watery eyes.

Allergy shots are indicated for patients whose symptoms are not adequately controlled by avoidance measures or medications, or for those who wish to reduce long-term use of medications.

Once the provider has determined the patient is an appropriate candidate for immunotherapy, a prescription is written for the preparation of antigens for allergen immunotherapy based on the patient’s individual allergy profile. The prescribing physician must specify the starting immunotherapy dose, the target maintenance dose, and the proposed immunotherapy schedule. Allergy shots are a common form of immunotherapy that involves giving increasing doses of antigens over time, building up to a maintenance dose.

The number of vials in the patient’s treatment set will determine the number of shots the patient receives at each visit. The two possible injections codes for administering allergy shots are:

95115   Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection

95117   2 or more injections

Three Tips for Navigating Coding

There are three important bits of information that must be considered to ensure claims for allergy services are paid: What constitutes a dose, unlikely medical scenarios, and payer limits.

Know What Constitutes a Dose

Per CPT® Assistant, a dose is defined as the number of antigens administered in a single injection from a multi-dose vial. Medicare, however, has a specific and restrictive definition of a dose for CPT® 95165.

Per local coverage determination (LCD) L34597, code 95165 is for reporting multi-dose vials of non-venom antigens. Effective Jan. 1, 2001, a dose is defined as 1 cc aliquot from a single multi-dose vial. Providers should report the number of units representing the number of 1 cc doses prepared. A maximum of 10 doses per vial is allowed for Medicare billing, even if more than 10 preparations are obtained from the vial. In cases where a multi-dose vial is diluted, you cannot bill Medicare for diluted preparations more than the 10 doses per vial allowed.

To report 95165, designate the number of doses. The code includes single or multiple allergens. If a multi-dose vial contains less than 10 cc, report the number of 1 cc aliquots that may be removed from the vial, up to a maximum of 10 doses per multi-dose vial. Your provider may bill for preparation of more than one multi-dose vial if medically necessary. You may bill payers other than Medicare for the number of planned doses expected to be administered from a multi-dose vial.

Billing Example 1

To bill a 10 cc multi-dose vial filled to 5 cc with antigen, the provider may bill Medicare for five doses/units since five 1 cc aliquots may be removed from the vial.

Billing Example 2

To bill two 10 cc multi-dose vials filled to 5 cc with antigen, the provider may bill Medicare for a total of 10 doses/units since five 1 cc aliquots may be removed from each vial. It’s important to remember that Medicare interprets the unit as a billable dose, defined as a 1 cc aliquot.

Treatment set vials are initially prepared with maintenance doses of antigens specific to the patient. Sequential diluted vials in the treatment set are created and administered to the patient from the most diluted vial, moving on to the next most diluted vial, and eventually up to the maintenance vial. The provider should not bill Medicare for the diluted preparations.

Billing Example 3

For a 10 cc multi-dose vial filled to 5 cc with antigen, the provider may bill a non-Medicare payer for 10 doses/units.

Consider Unlikely Scenarios

CPT® 95165 has a medically unlikely edit (MUE) for greater than 30 units/doses to recognize that different vials of maintenance antigens cannot be in the same vial (mold and pollen, for example). Therefore, some patients will be injected at one time from one vial, containing in one mixture all the appropriate antigens, while other patients will be injected at one time from more than one vial.

Some patients might not tolerate the targeted maintenance dose — indicated by local reactions, systemic reactions, or both — and their maintenance dose is lowered to the highest tolerated dose. If the patient’s doses are adjusted (due to reaction or missed treatments), and the antigen provided is more or fewer doses than originally anticipated, make no change in the number of doses billed.

Keep Payer Limits in Mind

Each practice is responsible for confirming payer coverage, coding, and payment parameters. There are a few things your practice can do to mitigate risk of noncompliance, and it starts with internal policy management efforts.

Review payer reimbursement policies associated with CPT® 95165 to determine which guidelines are being followed. These distinctions could be the difference between thousands of dollars and incidences of fraud, waste, and abuse. Track and incorporate evolving industry standards, making sure your policies are up to date in your practice. For accurate claim submission and adjudication, the patient’s third-party payer should be contacted to determine any coding and/or reporting requirements. Educate providers and staff on limitations and medical necessity requirements on a regular basis.

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