Pediatric Coding Alert

Surprise: Multi-dose prep deserves its own unit coding

May flowers may bring allergy sufferers to your practice in droves. But you can remain clear-headed when coding immunotherapy services with this action plan.
 
Because CPT contains different codes for allergen immunotherapy performance and supplies, you may be uncertain which code to use. When a pediatrician does allergy injections, "we have difficulty with 95115-95117 versus 95120-95125 and 95165," says Teresa Carrillo, coder at Children's Medical Center in Tucson, Ariz. To select the correct code, apply the following scenarios to your allergy claims.

Report Allergy Shots as 95115, 95117

When a pediatrician provides an allergy injection without mixing the serum, you should assign 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or CPT 95117 (... two or more injections). These two codes are for the injection services and do not include providing the extract, says Shelley Bellm, CPC, at Colorado Mountain Medical.
 
Example 1: A patient's allergist sends you vials to use for immunotherapy, and you perform the injections. "Because the physician only administers the allergen, you should report 95115 or 95117," Bellm says.
 
Choose 95115 or 95117 based on the number of injections the patient receives. To indicate that the patient received one allergen injection, use 95115, Bellm says. "Code 95117 indicates the patient received two or more allergen injections."
 
Be careful: Always report allergen immunotherapy codes 95115 or 95117 "one time, regardless of the number of injections performed," Bellm says. You should not specify each injection, she says.

Pitfall averted: Following the above billing advice can help you avoid denials. Before Bellm's office initiated basic coding training for their clinical support staff, they would indicate both 95115 and 95117 when administering two or more injections. When entering allergy codes this way, the practice faced denials for unbundling these codes.

Capture Injections and Extract With 95120-95125

Get out of the 95115-95117 zone when your practice mixes the serum. CPT uses two different code sets to describe allergen immunotherapy injections with allergenic extracts, says Chrissy Letsen, CPC, education and auditing specialist at Metropolitan ENT in Alexandria, Va. "When the physician uses a treatment board to mix each serum prior to administration, you should use 95120 (Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; single injection) or 95125 (... two or more injections)," she says.
 
Example 2: A pediatrician prescribes allergy immunotherapy for a patient. On the child's bimonthly therapy day, a nurse mixes the serum and gives the injections. In this case, you should report 95120 or 95125 to describe allergen immunotherapy including allergenic extract provision.
 
Codes 95120-95125 and 95115-95117 parallel each other in terms of quantity. Use 95120 as you do 95115 for a single injection. When a patient receives two or more injections with extract provisioning, report 95125.
 
Watch out: Pediatric practices typically report the injection service codes rather than the combination injection and serum codes. "Usually the allergist office would mix the serum, and the pediatrician would administer the injections," Letsen says.
 
In fact, many carriers do not cover combination serum mixing and allergen immunotherapy codes, Letsen says. But nonpayment does not usually cause a problem.
 
"Because 95120-95125 describe single-dose preparation and administration, the codes are rarely used," she says. Physicians find it easier to mix serum in multi-use vials than individually off treatment boards.

Code Multi-Dose Prep With 95165

When a staff member makes multi-dose vials, you should separately code the preparation and administration. "We bill for the serum with 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]) when we prepare it," says Karen Grisham, an allergy coder. Then report 95115 or 95117 when the patient receives the injections.

Example 3: A pediatrician prepares a 10-dose vial for a patient. The next week, a nurse administers one injection to the patient containing one dose from the vial. For the antigen preparation and provision, you should report 95165 with the number of doses. On the injection day, assign 95115.

 CPT defines a clinical dose as "the amount of antigens 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. Because the vial in example 3 contains 10 doses, you should report 95165 with a 10 in the units' box.