Billing Allergy Immunotherapy

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

95117 - Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections

95144 - Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose vial(s) (specify number of vials)

95145 - Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); single stinging insect venom

95146 - Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); 2 single stinging insect venoms

95147 - Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); 3 single stinging insect venoms

95148 - Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); 4 single stinging insect venoms

95149 - Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); 5 single stinging insect venoms

95165 - Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)

95170 - Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; whole body extract of biting insect or other arthropod (specify number of doses)

Definitions

• For allergen immunotherapy purposes a dose describes the amount of antigen(s) administered in a single injection from a multi-dose vial.

• CPT codes 95115-95117 describe the professional allergenic extract administration. (Injection only) CPT 95144 describes the allergist’s preparation and provision of single-dose vials for administration by another physician.

• CPT codes 95145-95170 represent antigen preparation. (Preparation only)

• CPT code 95165 includes single or multiple antigens.

CPT Codes 95115-95117

• Bill one CPT code 95115 or 95117 per date of service (DOS) and 1 unit in Box 24-G, days or units field.

• Do not bill CPT code 95115 and 95117 on the same DOS.

• Do not bill CPT code 95115 and 95117 if the antigen is self-administered by the patient.

CPT Code 95144

• To bill CPT code 95144, designate the number of single-dose vials prepared and provided.

• CPT code 95144 indicates only single dose vials.

• CPT code 95144 may only be used when a physician prepares an extract to be injected by another entity.

CPT Code 95165

• To bill CPT code 95165, designate the number of doses.

• CPT code 95165 does NOT include antigen administration.

• To bill for antigen preparation and administration, use component billing. (Samples below)

• If a multi-dose vial contains less than 10cc, bill the number of 1 cc aliquots that may be removed from the vial up to a maximum of 10 doses per multi-dose vial.

• If medically necessary, physicians may bill for preparation of more than one multi-dose vial.

CPT Code 95165 Billing Exceptions

If the antigens, i.e. mold and pollen, cannot be mixed together, CGS calculates the practice expense (PE) for mixing a multi-dose vial of antigens based on the following observed practice method:

• Physicians usually prepare a 10 cc vial and remove aliquots with a volume of 1 cc.

• 10, 1 cc aliquot doses equal the entire PE component for the service.

• Size or number of aliquots removed do NOT alter the PE for the service.

CPT Code 95165 Billing Samples

• To bill a 10 cc multi-dose vial filled to 6 cc with antigen, submit CPT code 95165 with 6 in the days/units field.

• If a physician removes 1/2 cc aliquots from a 10 cc multi-dose vial for a total of 2 doses, submit CPT code 95165 with 10 in the days/unit field. (Billing for more than 10 doses represents an overpayment for the practice expense vial preparation.)

• If a physician prepares two 10 cc multi-dose vials, submit CPT code 95165 the 20 in the days/unit field. (The number of aliquots removed from the vials does NOT change the number of doses billed.)

CPT Codes 95144-95170 Component Billing

• Services for CPT codes 95144-95170 represent a single dose.

• To bill, specify number of doses in the days/unit field.

• Use a code below the venom treatment number ONLY for “catch up” purposes.

• If a physician prepares the allergen and administers the injection on the same date of service, bill the appropriate injection code (CPT codes 95115-95117) AND the appropriate preparation code (CPT codes 95145-95170).

• Do NOT bill CPT codes 95144 AND an injection code (CPT codes 95115-95117).

CPT Code 95144 Billing Samples

Sample 1:

• Allergists bill CPT code 95144 and 2 in the days/units field to indicate preparation of 2 single dose vials of extract.

• Primary care bills CPT code 95117 and 1 in the days/units field to indicate the administration of 2 or more injections.

Sample 2 Component Billing:

Allergists prepares a 10-dose vial and develops a schedule to administer one dose per encounter over a predetermined period of time.

• Bill CPT code 95145 with 10 in the days/units field for the preparation.

• Bill CPT code 95115 for one injection.

Sample 3:

Allergist prepares a 10-dose vial and develops a schedule for the patient to self-administer the injections.

• Bill CPT code 95145 with 10 in the days/units field for the preparation. DO NOT bill an injection code.

Sample 4:

Allergist prepares a 10-dose vial for non-stinging insect venom and administers one injection.

• Bill CPT code 95165 with 10 in the days/units field for the preparation.

• Bill CPT code 95115 for one injection.

Venom Doses and Catch-Up Billing

Since physicians prepare most venom doses in separate vials, a respective dose of CPT code 95146-95149 represents a portion of two, three, four or five venoms. Medicare built savings into the reimbursement for the higher venom codes. Therefore, if a patient receives two-venom, three-venom, four-venom, or five-venom therapy, physicians should allow the highest possible venom level.

In multi-venom therapy the physician provides a portion of each venom amount. Due to patient reaction, venom administration may not remain synchronized and dosage adjustments must be made. If the physician makes an adjustment, he must synchronize the preparation to the highest-level venom as soon as possible.

Sample: A physician prepares 10 doses of CPT code 95148 in two vials. One contains 10 doses of three-vespid mix and another contains 10 doses of wasp venom. Because of dose adjustments, the three-vespid mix covers 15 doses. The physician must prepare 5 doses of CPT code 95145 for the “catch up”.

• Bill CPT code 95148 with 10 in the days/unit field for a patient in four-venom therapy.

• Bill CPT code 95145 with 5 in the days/units field.

Treatment Boards

To report treatment boards, use the antigen preparation vial CPT codes (95145-95149, 95165 and 95170) AND the component billing method. Use CPT code 95165 in place of 95144 for other than stinging/biting insects.

Sample: Allergist prepares a 10 dose vial for non-stinging allergen and administers one injection.

• Bill CPT code 95165 with 10 in the days/units field for the preparation.

• Bill CPT code 95115 for one injection.

Code 95170 Applies ONLY to fire ant extract.

Evaluation and Management (E/M) Services and Immunotherapy

To identify a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided, select the appropriate E/M code and append with modifier 25.

If you have any questions regarding allergen immunotherapy billing or need assistance with any other billing, please contact us by emailing info@mediclaimservices.com.