Pediatric Coding Alert

Allergy shots can help patients and be a profitable sideline for pediatricians, but sometimes there are coding problems involved with getting reimbursed for the antigen itself -- the substance prepared for the individual patient according to their need.

Antigen is custom-ordered for each patient by their allergic medical needs, relates Dawn Buchanan, billing specialist for Pediatric Care Medical Group of Huntington Beach, CA. The substance only comes in yearly supplies. If a patient leaves our facility prior to using up their particular antigen it is then shipped to their new physician. I take the number of doses given per week and multiply it by 52 weeks in a year. This gives me the yearly quantity for billing, and then I multiply that figure by our bill rate. The CPT code I use is 95165 which clearly states, Specify number of doses. It does not say specify number of days or weeks or months, just doses. When the injections are given we use CPT 95117 for the administration of antigen. This CPT code does not include the antigen cost itself.

Until recently, I have never had any problems in billing and collecting the antigen monies from neither large or small insurance carriers. But, in current months, I have run into a snag with one carrier (Humana) in particular, Buchanan adds. They only want to pay it in 30-day increments, she says. But we have to pay it for the whole year's supply. How do I overcome this obstacle? asks Buchanan.

Getting Paid

Theyre using the right code -- 95165, says Deidre Reitwiesner, insurance clerk for Seth C. Craig, MD, PC, a pediatrician and allergist in Fredericksburg, VA. This code is for professional services for the supervision and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses), she explains. Note that CPT specifically states to specify the number of doses. Immunotherapy is defined as the parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage which is maintained as maintenance therapy.

Those two quotations from CPT have been essential to helping Reitwiesner solve the problem of being reimbursed for antigen administration with Medicaid. We photocopied those pages from the CPT coding book, and highlight the code, and where it says `specify number of doses, the billing clerk tells us. Medicaid had been telling us it was an excessive number of doses, but we got them to understand its for six months. (Reitwiesner bills every six months for antigens, rather than once a year, and this seems to be working.)

Along with the highlighted pages, Reitwiesner sends a form called Allergenic Extracts Units Justification. The form has three possible items to be checked. They are as follows:

__ This patient has multiple allergies and requires two sets of allergy extracts to administer this many allergens.

__ These are the initial treatment sets and contain all the directions required to build the patient up to the final maintenance dosage.

__ These are large quantities of allergy extract and are expected to last for six to 12 months of allergy injections.

It is the third item that applies in Buchanans case. At the bottom of the form is the following statement: Please process claim for payment. CPT code 95165 is for _____ doses of allergy extract equal to _____ vials. Please see attached documentation. The patients name goes on the form, the highlighted CPT pages are attached, and this approach is getting claims paid for Reitwiesner.

However, insurance clerk does think 95125 is a better code for the administration of the injection than 95117. We mix our own antigens, says Reitwiesner. 95125 is for professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; two or more injections. 95117 is for professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections. By using the 95125 code, it pays us for doing a mixing, says Reitwiesner. 95115 and 95117 are for if another office has made the antigen, she adds.