Otolaryngology Coding Alert

Otolaryngologists frequently place patients suffering from allergies on injection programs. If the otolaryngologist gives the shots, he or she is likely to do the allergy testing, which also includes preparing shots that normally are injected twice a week into the patient in small doses until the body builds up a resistance to them.

Sometimes, however, the specialist who tested for the allergies is located far from the patient, making two visits a week for injections quite inconvenient.
So, some patients may arrange to use other physicians closer to their workplace, or even perform the injections themselves, following an early stage in the physicians office that determines that no adverse reactions to the shots have occurred. Typically, patients would take the first five or six shots in the otolaryngologists office before injecting themselves at home.

Depending on the circumstances, the otolaryngologist may have tested the patient for allergies, prepared antigens that the patient self-injects, delivered the injections to the patient in the ENT office, or any combination of the above.

The fact that the physician who prepares the antigens for the allergy shots may not end up doing the injections is one reason why so many codes are required for billing and reimbursement in the treatment of allergies, says Susan Callaway Stradley, CPC, CCS-P, a consultant in the medical division of Elliott, Davis & Co., a healthcare accounting firm in Augusta, GA.

Coding for Injection Administration

Both 95115 (professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) and 95117 (two or more injections) should be used by any physician who gives an injection to a patient from a vial of material that was prepared at another time or at another location, says Stradley, who was recently named the 1998 Coder of the Year by the American Academy of Professional Coders.
Codes 95115 or 95117 should be used even if the material was made by the same physician who administers the injection, but comes from a vial previously prepared especially for that patient.

Another example of when 95115 or 95117 should be used is if the patient decides to go to another physicians office for the pre-prepared injections.

Coding Both Material and Injection

The next series of codes, 95120-95133 (see box in next column for definitions), should be used when the physician actually draws up each individual shot separately.
The doctor has a board with as many as 300 different vials of antigens (for roaches, dust mites, etc.). Each patient has an injection schedule in their chart, and each individual antigen is mixed when the patient arrives so that the physician has more control over the doses the patient receives by means of titrating dosages, that is, modifying doses in tiny increments.

Any claim using 95120-95133 codes cannot also contain codes 95115 or 95117, because the injection fee(s) are already included in the material codes, says Stradley, who also worked in an allergists office for five years and spent close to a year as an ENT coder.

Allergy Codes CPT 1999: 95115 - Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection 95117 - Two or more injections 95120 - Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; single injection 95125 - Two or more injections 95130-95133 - Single, two, three or four stinging insect venoms 95144 - Professional services for the supervision and provision of antigens for allergen immunotherapy, single or multiple antigens, single dose vials (specify number of vials) 95145 - Professional services for the supervision and provision of antigens for allergen immunotherapy (specify number of doses); single stinging insect venom 95146-95149 - Two, three, four, and five single stinging insect venoms 95165 - Professional services for the supervision and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) 95170 - Whole body extract of biting insect or other arthropod (specify number of doses) 95180 - Rapid desensitization procedure, each hour (e.g., insulin, penicillin, horse serum) 95199 - Unlisted allergy/clinical immunologic service or procedure 99070 - Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided) HCPCS: A4211 - Supplies for self-administered injections. Note: When a drug that is usually injected by the patient (e.g., insulin or calcitonin) is injected by the physician, it is excluded from Medicare coverage unless administered in an emergency situation (e.g., diabetic coma). A9270 - Non-covered item or service. Note: Medicare jurisdiction; local or DME regional carrier.

Reimbursement for Material Only

Another group of codes, 95144-95170 (see next column for definitions), is used for the provision of the antigenthe mixing of the vials that are specific to each patient.
Code 95144 is for single-dose vials, where the physician empties a vial, injects the patient, and disposes of the bottle. This code is billed according to the number of vials prepared for the patient.

At the subsequent visit, the physician uses the next bottle marked in sequence. Stradley says that in most parts of the country, this is the least common way to provide antigens to patients.

Both 95144 and the subsequent codes, she says, should be used in conjunction with 95115 and 95117.
Codes 95145-95170 are billed according to the number of doses, not the number of antigens in the doses. In other words, if the vial contains 20 different antigens and eight doses, the physician bills for eight doses.
The physician who created the antigen material puts the number of doses in the units column of the claim form when it is submitted.

Injection codes 95115 and 95117 also should be billed every time the patient receives an injection, and both codes should never have anything other than a 1 entered in the units column on the HCFA 1500 universal claim form, which is also used by commercial carriers.

Some insurance companies regularly fail to correctly reimburse the number of antigen units claimed even when the proper coding is used, says Tina McElhaney, billing/surgical coordinator at Atlanta Center for ENT.
Typically, McElhaney says, only a fraction of the number of doses claimed by her clinic are reimbursed, even though the correct amount is clearly indicated on the claim forms.
McElhaney says the amount of allergy serum per bottle is mixed in 10-dose increments; therefore, every bottle is billed as containing 10 doses or units. On most claims, she explains, only one unit is reimbursed.

I find that 80 percent of my phone calls [to the payers] are to correct this problem, McElhaney says. Once I have a customer service representative on the phone, it is clearly recognized and corrected. However, she relates, the end result is that reimbursement has been delayed 10 to 14 days.

She recommends highlighting the number of units on the form with a bright coloras doing so has cut, but not eliminated, the number of denied claims in this area for her practices claims.

Another solution, says Stradley, is for offices to switch to electronic billing, which should help eliminate the problem.

Use HCPCS Supply Code for Syringes

McElhaney also says carriers routinely deny the purchase of syringes at her office by patients who plan to self-inject at home. The denials say the syringes are considered part of the original procedure code and should not be billed separately or not covered.

The claim is being processed as if we were billing for the syringe we used for the patients injection. I have tried different procedure codes, such as 99070 (supplies and materials [except spectacles] provided by the physician over and above those usually included with the office visit or other services rendered), and A9270 (HCPCS non-covered item or service), explains the billing coordinator.

McElhaney says even carriers that cover syringes for office injections often do not reimburse the patient, who then is informed the supply is covered if it is coded correctly, implying if we code differently they will be paid. She now writes syringes in the space next to the code on the claim form. In the units box, she writes 1 box of 25 for self-administered injections. Since she began doing so, more, but not all, claims are being reimbursed.

Stradley points to an existing HCPCS codeA4211 (supplies for self-administered injections) and recommends using it. Most, but not all, carriers now require this specific code, rather than 99070, which is a generic CPT supply code that had to be accompanied by a manual description of the supply being billed.

Still, coders should contact payers and find out whether they still prefer the generic supply code (99070) accompanied by a manual description or the HCPCS code, in this case the A4211, Stradley says.

She also cautions that, depending on the individual carriers policy, they may not pay for the A4211 separately.
Some carriers, Stradley adds, maintain that the patient would not be able to self-inject without syringes, and since the same physician gave the patient the allergenic extract, the syringes should be included in that claim.