How to Bill 95165 Right and Stay Out of Audit Trouble

Get the lowdown on 3 immunotherapy requirements most coders miss

How accurate is your 95165 billing? If you can't say for sure, you're probably not reporting your allergist's allergen supervision services correctly and could be risking audits. But if you pay attention to three crucial 95165 billing guidelines, you'll reduce your chances of unwanted scrutiny, coding experts say.
OIG Survey Reveals 95165 Mistakes
A recent HHS Office of the Inspector General (OIG) survey of 600 general allergy, ENT and family practice offices indicates that 40 percent of physicians incorrectly report 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]), the American Academy of Otolaryngic Allergy (AAOA) Coding Advisory states.
 
One of the reasons for the billing errors is that CPT and Medicare differ in defining the dose specified in 95165, allergy coding experts say. So, knowing the differences between the two billing methods is crucial for correctly reporting antigen supervision services.
 
Follow these three field-tested tips to improve your antigen billing:
1. Bill Based on Payer-Defined Dose
Don't assume that a "clinical dose" and a billable dose are the same, or you'll be well on the way to 95165 errors.
 
CPT defines a clinical dose as "the amount of antigen(s) administered in a single injection from a multiple-dose vial," says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "On the other hand, Medicare defines a billable dose, not a clinical dose, as 1 cc."
 
Although a physician may administer any antigen amount based on clinical judgment, Medicare allows billing only the maintenance concentrate, says J. Spencer Atwater, MD, president of the Joint Council of Allergy, Asthma and Immunology. Because CMS calculates the antigen costs and administrative overhead based on preparing 1 cc, you may report only a concentrated dose or the highest vaccine concentration the allergist determines is the therapeutically effective dose.
 
So how do the different dosage interpretations impact 95165 billing? Take a look at the following example:
 
A physician prepares a 10-dose vial for a patient and administers one injection to the patient containing one dose from the vial. For the antigen preparation and provision, you should report 95165 x 10 for non-Medicare payers. Because CPT interprets a dose as equivalent to the amount of serum the physician draws up in the injection and the vial contains 10 doses, the antigen preparation and provision code should contain a 10 in the units box. In addition, assign 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) for the one injection.
 
Using the same example above, if the 10-dose vial is 5 ccs, you should [...]

- Published on 2003-09-15