# Documentation Requirements for 95165



## klamm (Mar 28, 2017)

I am unable to locate any definitive guidelines regarding the documentation that is required to code 95165.  Does the physician have to specifically state that they supervised the mixing of the vials?  Can 20 doses per vial be coded for BCBS or Aetna?  I know for Medicare it's 10 doses per vials.  Is the following documentation enough to code 95165 qty of 40 along with 95117?

*Patient arrived ambulatory in NAD & without c/o, for scheduled immunotherapy allergen extract injection(s). Patient ID verified via name/DOB. Escorted patient to procedure/exam room. Allergy pre-assessment questions asked and daily environmental (Houston) pollen report reviewed.  Patient did not voice localized adverse effect of last immunotherapy injection (see pre-injection assessment questions). 
Pt starting new maintenance vials, dose reduced per protocol guidelines. 
Entered charges (CPT 95165) Quantity 20 doses per 10 ml vial.  Two vials  X 20 doses = Qty. 40 doses.
Concurrent DX asthma with in-clinic Peak Flow today = NA. Patient approved to proceed/receive immunotherapy today by verbal order received from Dr. Jennifer McCracken. Nurse/Patient both verified correct patient ID on vial(s).   Verbal order received to administer 0.25 ml from allergen extract vial A, Cat, RW, Tree and Wed Pollen 1 : 1 conc; administered SC to right arm.  Verbal order received to administer 0.25 ml from allergen extract vial B, DM and Grass Pollen 1 : 1 conc; administered SC to left arm.
Patient instructions as follows provided:  
(Is the patient approved for Allergen Extract Vaccination today?  Yes
Immunotherapy written consent on file?  Yes
Has the nurse and the patient verified the correct patient identification on the vial(s)?  Yes
Patient instructed to remain in clinic for observation/monitoring a minimum of 30 minutes after Allergen Extract Vaccination(s)?  Yes
Patient completed thirty minute post injection wait time with the following local reactions to injection sites.
Post allergen administration assessment:  
Vial A:  Wheal:  10 mm     Flare:   12 mm
Vial B:  Wheal:  12 mm     Flare:   14 mm
Patient was reminded of post injection instructions and was reminded to report largest growth at the site. Patient was released home in no apparent distress. *

Thank You
KJMartin, CPC


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## Irma (Feb 9, 2018)

*95165*

Hello, 

When we first started allergy testing and treatment about 2 years ago, I was lost. 
I did not have a clue how insurances would respond to our claims. 

I would like to exchange information with you regarding my findings and such. 

Would you be interested in having a conversation? 

Thank you, 

Irma Ibarra,  CPC


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## klamm (Aug 15, 2018)

That would good.  I still can't really find anything definitive regarding documentation guidelines for 95165.   The clinic staff is always trying to code 95117 along with 95165 for every visit, I can't find anything that clearly states why this can't be done.  

Thanks
Kendra Jo Martin, CPC
kejmarti@utmb.edu


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## Wiethoff (Sep 12, 2018)

*Charge of Dose*

It says that you have 20 doses per 10 ml vial. With 2 vials you are charging 40 doses for 95165.

According to Medicare guidelines a dose is defined as one (1) cc. Doesn't that apply to every insurance company?

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 that case you would charge 95165 x 20 doses total for two vials.


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