Maximizing Reimbursement: Unraveling The Nuances Of Billing Cpt 95165 Across Insurers

CPT 95165 is a medical procedural code for allergen immunotherapy services and procedures. CPT 95165 can be used to report professional services for the supervision of preparation and provision of antigens for allergen immunotherapy. The code includes single or multiple antigens, and the number of doses needs to be specified. CPT 95165 is highly complex and requires well-educated medical coders to ensure accurate and timely reimbursement.

CPT 95165 code definition

CPT 95165 is a medical procedural code for allergen immunotherapy services and procedures. CPT 95165 can be used to report professional services for the supervision of preparation and provision of antigens for allergen immunotherapy. The code covers the professional service of preparation and provision of antigens for allergen immunotherapy, as well as the administration of allergy immunotherapy (allergy shots).

The CPT 95165 code is used when a patient undergoes allergy testing and it is determined that they have allergies to one or more substances. Antigens for allergen immunotherapy are then prepared using the allergy testing results, with the goal of desensitizing the patient to the allergens. This is done by administering diluted antigens via injection, gradually increasing the dosage over time until a maintenance dose is reached.

The CPT 95165 code requires the amount of doses to be specified, with Medicare Part B recognising a maximum of 30 units. The number of doses leading to the maintenance dose are diluted and placed into multiple vials, with each subsequent vial containing a higher concentration of the antigen. The number of vials in the patient's treatment set will determine the number of shots the patient receives at each visit.

It is important to note that Medicare Part B will only pay for the original vial of non-diluted maintenance antigen, even if the patient receives smaller doses. Therefore, accurate billing for CPT 95165 requires specifying the number of doses and adhering to payer-specific guidelines, particularly for Medicare.

CPT 95165 billing guidelines

CPT 95165 is a medical procedural code for allergen immunotherapy services and procedures. It covers professional services for the supervision of preparation and provision of antigens for allergen immunotherapy. CPT 95165 can be used for billing professional services to supervise the preparation and provision of antigens for immunotherapy for a single or multiple antigens, with the number of doses specified.

The billing guidelines for CPT 95165 are as follows:

• CPT 95165 requires the specification of the number of doses. The doses leading up to the maintenance dose are diluted by a significant amount of sterile saline.
• The provider must mix and prepare the antigens for allergen immunotherapy. CPT 95165 is used when the provider prepares one or more antigens.
• CPT 95165 is defined as "Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)."
• A physician may delegate certain tasks, such as physical antigen/serum mixing, patient instruction for serum injection, and providing serum vials to the patient. However, they must personally select the allergens, determine specific concentrations and dilutions, and order the shot schedule.
• The interpretation of CPT code 95165 has been controversial due to its inclusion of the concept of a 'dose', which is not defined in the CPT manual. Traditionally, a dose was defined as the amount of antigen given in a single injection.
• Medicare has a specific and restrictive definition of a dose for CPT 95165, defining it as a 1 cc aliquot from a single multi-dose vial, with a maximum of 10 doses per vial allowed for billing.
• For a 10 cc multi-dose vial, providers should bill for the number of 1 cc aliquots that can be removed, up to a maximum of 10 doses.
• Providers may bill for the preparation of more than one multi-dose vial if medically necessary.
• Payer reimbursement policies associated with CPT 95165 should be reviewed to determine the guidelines being followed, as these can vary significantly.

CPT 95165 reimbursement

CPT 95165 is a medical procedural code for allergen immunotherapy services and procedures. It covers professional services for the supervision of preparation and provision of antigens for allergen immunotherapy. CPT 95165 can be used for billing professional services to supervise the preparation and provision of antigens for single or multiple antigens immunotherapy.

The reimbursement for CPT 95165 is particular due to the restrictive definition of a "dose" by Medicare. No other payer has this same definition, stating in the 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 addition, BCBSTX limits payment for allergy serum to the amount actually provided to the patient on a given date of service but no more than 60 units per two months. This policy does not apply to rapid desensitization.

To ensure accurate and timely reimbursement for CPT 95165, medical coders need to be well-educated about the complex billing process for allergen immunotherapy. There are four key components of allergy services that should be considered when billing CPT 95165: the provision of antigens for allergen immunotherapy, administration of allergy shots, skin testing, and allergy shots.

Skin testing is the gold standard for determining what a patient is allergic to and is used alongside medical history. Allergy shots are indicated for patients whose symptoms cannot be controlled by avoidance measures or medications or for those looking to reduce long-term medication use.

The prescribing physician must specify the starting immunotherapy dose, target maintenance dose, and proposed immunotherapy schedule. Allergy shots involve giving increasing doses of antigens over time, building up to a maintenance dose. The number of vials in the patient's treatment set determines how many shots the patient receives per visit.

To report CPT 95165, the number of doses must be designated. The code includes single or multiple antigens. 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. Providers may bill for the preparation of more than one multi-dose vial if medically necessary.

CPT 95165 and Medicare

CPT 95165 is a medical procedural code for allergen immunotherapy services and procedures. It is used to report professional services for the supervision of preparation and provision of antigens for allergen immunotherapy. CPT 95165 can be used for multiple antigens or a single antigen, and the number of doses needs to be specified.

When billing CPT 95165 for Medicare patients, it is important to understand Medicare's definition of a "dose". Medicare defines a dose as 1cc of extract and does not cover dilutions. The reimbursement is based on this definition. The practice expense (PE) inputs for CPT 95165 are based on the assumption that ten doses are included in each 10cc vial of antigens. Therefore, if an allergist prepares a 10cc multidose maintenance vial, they can bill a maximum of 10 doses to Medicare, even if they obtain more than 10 doses from the vial.

If a multi-dose vial contains less than 10cc, providers should bill Medicare for the number of 1cc aliquots that can be removed from the vial. For example, if a 5cc multidose vial is filled completely, a maximum of 5 doses can be billed to Medicare. If medically necessary, providers can bill for more than one multidose vial, as long as they document the reasons in the medical record.

Medicare has assigned a medically unlikely edit (MUE) of 30 units per day for CPT 95165. This means that claims for more than 30 units per day are considered "medically unlikely".

To correctly bill CPT 95165 for allergen immunotherapy, it is important to understand the four components of allergy services:

• Provision of antigens for allergen immunotherapy
• Administration of allergy shots
• Skin testing to determine what a patient is allergic to
• Allergy shots are indicated for patients whose symptoms are not controlled by avoidance measures or medications, or for those who wish to reduce long-term medication use

Additionally, there are three key considerations for navigating the coding:

• Know what constitutes a dose: Medicare has a specific and restrictive definition of a dose for CPT 95165, which is different from the definition used by other payers.
• Consider unlikely medical scenarios: CPT 95165 has an MUE of greater than 30 units/doses to account for cases where different antigens cannot be mixed and must be kept separate.
• Keep payer limits in mind: Review payer reimbursement policies and confirm coverage, coding, and payment parameters to ensure accurate billing and mitigate the risk of non-compliance.

CPT 95165 and private payers

CPT 95165 is a medical procedural code for allergen immunotherapy services and procedures. It covers professional services for the supervision of preparation and provision of antigens for allergen immunotherapy. It can be used for multiple antigens or a single antigen, but the number of doses must be specified.

Allergen immunotherapy is a complex process that requires accurate medical coding to ensure timely reimbursement. There are four key components to allergy services that should be considered when billing CPT 95165:

• Provision of antigens for allergen immunotherapy: This involves preparing antigens based on the patient's individual allergy profile and the prescribed immunotherapy dose and schedule.
• Administration of allergy shots: Allergy shots are given to patients whose symptoms are not controlled by other measures or who want to reduce long-term medication use.
• Skin testing: This is used alongside medical history to determine what a patient is allergic to.
• Allergy immunotherapy drops: Some payers will cover these if appropriate documentation is provided.

When billing CPT 95165, it is important to know what constitutes a dose. CPT® Assistant defines a dose as the number of antigens administered in a single injection from a multi-dose vial. However, Medicare has a more restrictive definition for CPT 95165, defining a dose as 1 cc aliquot from a single multi-dose vial. For Medicare billing, providers should report the number of units representing the number of 1 cc doses prepared, with a maximum of 10 doses per vial. If a multi-dose vial contains less than 10 cc, providers should report the number of 1 cc aliquots that can be removed, up to a maximum of 10 doses per multi-dose vial.

It is worth noting that Medicare Part B has a medically unlikely edit (MUE) of any amount above 30 units to account for different vials of maintenance antigens that cannot be mixed. Therefore, providers should be careful when billing for supervision of preparation for Medicare Part B patients, as Medicare will not pay for diluent beyond what is needed to create the maintenance antigen.

While Medicare's definition of a "dose" is specific to billing purposes, it is crucial for allergists to understand this definition to ensure accurate billing for CPT 95165.

Frequently asked questions