Otolaryngology Coding Alert

Spot the 95165 difference or forfeit pay

If you're not clear on whether to bill 95115 or 95165 when your allergist provides and supervises immunotherapy, you'll benefit from these three tips offered by allergy coding experts. In essence, receiving proper reimbursement hinges on separating injection-only codes from antigen and antigen-preparation codes.
 
Allergy immunotherapy know-how is a must because patients diagnosed with certain common allergies will receive doses of antigens roughly 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.

1. Distinguish Between Extract Prep and Injection
 
You should determine whether the physician provided the allergenic extracts or simply administered the injection. Use 95115 (Professional services for allergen immuno-therapy not including provision of allergenic extracts; single injection) and 95117 (... two or more injections) for the injection service. Report these codes one time, regardless of the number of injections the physician gives.
 
If the physician prepares the antigen and administers one injection, you should report 95115 along with 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]).

2. Use 95144 With Care

Report 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]) when the physician supervises antigen provision.
 
Use 95144 only when the physician provides the antigen to be injected by another physician, which does not occur often in allergy practices. "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. (See "NCCI Creates Immunotherapy Prep and Diagnostic Bundles" on page 30 for more on reporting 95144 with 95165.)
 
You should not use codes 95120-95134 (Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract ...), because they represent complete services that include both the injection and its preparation.

3. Tally the Doses

The Medicare Physician Fee Schedule amounts for 95144-95170 are for a single dose. You must specify the number of doses the physician provides. For example, an allergist prepares a 10-dose multivial and administers one injection to the patient. You need two codes: