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Internal Medicine Coding Alert

Think Youve Learned Your Immunotherapy ABCs? Think Again

Published on Tue Jul 01, 2003

Allergy season brings new patients into your office each day, so you must be proficient enough in immunotherapy coding to know whether to bill 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]).
 
Allergy immunotherapy know-how is a must because patients diagnosed with certain common allergies will receive doses of antigens close to once a week, says Cindy Schroeder, CPC, CPC-H, LPN, of Merit Care Health Systems in Fargo, N.D. The physician starts the patient on a weak dose and increases the potency until the dose reaches maintenance level, she says.
 
Coding for these injections is not as easy as it seems. Some coders want to report 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) for allergy injections. But Schroeder warns that this code is for administering injections, such as antibiotics, and does not include allergy immunotherapy.
 
Receiving proper reimbursement hinges on separating injection-only codes from antigen and antigen preparation codes. In addition, you must understand the subtle difference between coding for insect venoms as opposed to other antigens. Take a look at the following allergy immunotherapy ABCs, which will get you ready to face the allergy season head-on.

Administration Preparation and Doses

First, you should determine whether the physician provided the allergenic extracts or simply administered the injection. There are sets of codes for each circumstance:

  95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) and 95117 ( two or more injections) are the two component codes that represent the injection service. Report these codes one time, regardless of the number of injections the physician gives.
 
 95144 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single-dose vial[s] [specify number of vials]) and 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]) represent the supervision and provision of the antigens.
 
Note that you should not use codes 95120-95134 (Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of
allergenic extract ...) because they represent complete services that include both the injection and its preparation.
 
If the physician prepares the antigen and administers one injection, then you should report 95115 along with 95165. Use 95144 only when the physician provides the antigen to be injected by another physician, which does not often occur in internal medicine. 95144 is not favorable with insurance companies or physicians because it is very costly, says Karen Jernigan, CPC, CMIS, office manager at the Asthma, Allergy, and Immunology Clinic LLC in James Island, S.C. The Medicare Carriers Manual states that a physician should use a single-dose vial only as a way to ensure proper dosage amounts for injections. CMS assumes that internists are capable of administering proper doses from the less expensive multiple-dose vials. Even when a physician bills 95144, the payer reimburses him at the multiple-dose-vial (95165) rate in some areas of the country.
 
The Physician Fee Schedule amounts for codes 95144-95170 are for a single dose. You must specify the number of doses the physician provides. For example, an internist prepares a 10-dose multivial and administers one injection to the patient.

You need two codes:
  95165 x 10 (placed in the units box)
  95115
 
Sometimes, the physician adjusts the patients doses. If a patient has an adverse reaction to an antigen and the antigen dosage is more or less than anticipated, the physician does not make a change in the number of doses for which he bills.
 
Remember that Medicare will pay only for a reasonable supply of antigens prepared for the patient. A reasonable supply is considered to be no more than 12 weeks. Documentation must support the medical necessity, and proper ICD-9 codes must accompany the claim.

Bee and Other Insect Venom Injections
 
Physicians will see patients with a variety of allergic reactions, including reactions to insect venom. You do not code all injections the same and will need to use separate codes with insect antigen doses:

 95145 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy [specify number of doses]; single stinging insect venom
 95146 two single stinging insect venoms
 95147 three single stinging insect venoms
 95148 four single stinging insect venoms
 95149 five single stinging insect venoms
 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).
 
The main problem you may encounter with these codes is that you must be aware of the number of stinging insect venoms you are reporting, Jernigan says. She adds that, when you bill for venoms, the number of insects and the number of doses is important. This is different from  allergen antigen coding in that the number of antigens in the vial is not relevant, she says.
 
CPT holds that these codes do not include the administration of the antigen. If an internist prepares two doses of an antigen containing three stinging insect venoms, the code would be 95147 x 2 and 95117 for the administration. Whether the doses come from the same multiple-dose vial or a series of vials doesnt matter because the code describes the dose, not the bottle.
Circumstances of E/M Visit
 
What should you do when you have to see a patient for an office visit and administer an injection? You can bill for both services, but only under certain circumstances. You can code separately for the office visit when the patient is being seen for a condition other than receiving allergy injections, Jernigan says. CPT reiterates this point that you can report an office visit in addition to allergy immunotherapy only when other significant identifiable services are provided during the visit. This can include an examination of the patient, interval history and the evaluation of diagnostic tests. You need to use modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) with the E/M visit.
 
Schroeder says that most insurance companies bundle the injection into the E/M visit. Even in these circumstances, though, she reminds coders to bill for the supply of the antigen. You should check with your payer to determine its policy on E/M visits and allergy injections. 
 
Jernigan offers an example of an asthma patient who comes in for an asthma management visit and receives an injection. You would append modifier -25 to the office visit code, such as 99211-25. Showing a different diagnosis code related to the office visit as opposed to the allergy injection helps, but it is not necessary, Jernigan says. For instance, if the focus of the office visit is the discussion of prescription management for the asthma, you would use diagnosis codes V58.69 (Long-term [current] use of other medications) and 493.xx (Asthma) for the office visit and a code from the 477 series (Allergic rhinitis) for the allergy injection. Make sure that the documentation shows that the injection is separately identifiable from the office visit.
 
Other coders advise that the key to receiving reimbursement for both services is not separate diagnosis codes but appropriately documenting the significant, separately identifiable E/M service in the medical record.  If, for instance, a patient with allergic asthma (493.9x) presents for an evaluation of his condition to determine whether a change in medication or dosing should occur and receives his allergy injection, you could report 493.9x for both services. Your best bet, as always, is to ask your local carrier for its policies before reporting these services, coding experts say.

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