Pediatric Coding Alert

Question:  If our pediatrician provided allergy shots, what is the correct way to report these allergy shots for patients receiving five injections? Not sure if I have to report it with both 95115 and 95117? Also, if our doctor is observing the patient for an additional half hour or so after providing the injections, should I report this time spent with the patient separately? If so, what is the code I should report?

Answer:  When your pediatrician provides only one injection on a given day as part of the allergy immunotherapy, you will report it with 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection). Therefore, a series of one injection over five different encounters would result in reporting 95115 for each service date.  But if your doctor provided more than one injection on one day as it seems to be in the case scenario that you have provided, you will report it with 95117 (…2 or more injections). Irrespective of the number of injections provided, you should report any number beyond one with one unit of 95117 for a patient on one calendar date of service.

You need to note that 95117 is not an add-on code that you would report. This means you will not have to report 95115 for the first injection and then report 95117 for the additional injections that your pediatrician administered. Instead, you would report 95117 only when more than one injection is provided.

Also, 95115 and 95117 are bundled by Correct Coding Initiative (CCI) edits with the modifier indicator ‘0,’ which means that you cannot report these two codes for the same patient on the same calendar date of service.

The CPT® codes 95115 and 95117 include any time your clinician spends in providing observation services to check if the patient experiences any allergic reactions after the administration of the injection(s). So, the time spent by your pediatrician in observation should not be reported separately as it is part of the service described by 95115 and 95117.

But, if your pediatrician performed and documented a significant, separately identifiable evaluation of the patient during the same session, you can report this service with an appropriate E/M code (such as 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient...). However, you will need to append the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) to the code. Remember that this separately identifiable service must demonstrate management of a problem or condition that patient is experiencing. It is not simply performing a history and physical to determine if the allergy shot is contraindicated on that day. This latter assessment is included in the pre-service work of the injection.