Pediatric Coding Alert

Question: On claims containing a preventive medicine service and an office visit code, an insurer is reducing the payment on the second E/M service. Is this correct?

Tennessee Subscriber

Answer: Unfortunately, some insurers are adopting this policy. For instance, United Healthcare (UHC) pays the second service -- the problem-oriented portion billed with 99201-99215 (Office or other outpatient services) and modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service) -- at a lesser rate when reported with a preventive medicine service (99381-99384, New patient; 99391-99394, Established patient). The payer bases the reduction on the belief that same-day E/M services involve some duplication of services. By reducing payment for the significant and separately identifiable problem-oriented service, the insurer rationalizes that it eliminates paying twice for the duplicated portions.

Question: Our pediatric practice started offering allergen immunotherapy. The nurse explained, "We have ordered multi-dose vials for injections. There are approximately 15 bottles of allergy shots. Injections are made from these bottles.

Colorado Subscriber

Answer: For the extract preparation, you should bill 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]). Use units to report the number of doses.

CPT interprets a dose as equivalent to the amount of serum the nurse draws up in the injection. For instance, a nurse mixes serum in a multi-use vial containing 10 doses, you would enter a "10" in the units box following 95165.

Medicare requires direct supervision for antigen preparation. So based on CMS' incident-to rules when a nurse provides this service, a pediatrician must be in the office suite. Best bet: Check major payers' incident-to requirements before mixing serums outside pediatrician hours, such as on Saturdays or early mornings. Otherwise, you may not be able to charge for extract preparation due to not meeting incident-to criteria.

Next step: Report the administration with 95117 (Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections). Because the nurse administered two injections, 95117 is the appropriate code. When she administers one injection, use 95115 (... single injection).

Take-away tip: You may bill 95165 and 95117 on different days for the same patient. Offices usually prepare multi-dose vials on a weekly basis, which is when you should report the substance provision. Then, you should code the administration when the patient receives his shots.

-- Answers to You Be the Coder and Reader Questions answered/reviewed by Joel Bradley Jr., MD, FAAP, a pediatrician with Premier Medical Group in Clarksville, Tenn.; Richard H. Tuck, MD, FAAP, a national pediatric coding speaker and educator.