Primary Care Coding Alert

If you're billing incorrectly for 95165, you're not alone a recent survey found that 40 percent of physicians code this service incorrectly. These findings are prompting audits that are also targeting improper documentation and supervision, so make sure you fix your problems before the OIG and CMS start scrutinizing your billing practices.
 
Recently, the Office of the Inspector General (OIG) surveyed 600 ENT, general allergy and family practice offices that bill for allergy services to define how physicians interpret and bill 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]), according to the American Academy of Otolaryngic Allergy (AAOA) Coding Advisory. Because CPT and Medicare differ in how they define the dose specified in 95165, the survey discovered that 40 percent of physicians bill the code incorrectly. Therefore, you should pay close attention to the two billing methods for 95165.

Bill Based on Payer-Defined Dose

The AMA and CMS have two different definitions of a dose as defined in 95165. CPT defines a clinical dose as "the amount of antigen(s) 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. "On the other hand, Medicare defines a billable dose, not a clinical dose, as 1 cc."

Although a physician may administer any amount of an antigen, based on clinical judgment, Medicare allows billing only the maintenance concentrate, says J. Spencer Atwater, MD, president of the Joint Council of Allergy, Asthma and Immunology. Because CMS calculates the antigen costs and administrative overhead based on preparing 1 cc, you may report only a concentrated dose or the highest concentration of the vaccine that the family physician (FP) plans on using as the therapeutically effective dose.
 
Let's compare these two definitions and how they impact billing. Consider how you would report 95165 for non-Medicare carriers in the following clinical example:
 
A physician prepares a 10-dose multidose vial for a patient and administers one injection to the patient containing one dose from the vial.
 
For the antigen preparation and provision, you should report 95165 x 10. Because CPT interprets a dose as the equivalent to the amount of serum drawn up in the injection, and the vial contains 10 doses, the antigen preparation and provision code should contain a 10 in the units box. In addition, assign 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) for the one injection.
 
Using the same clinical example, if the 10-dose multi-dose vial is 5 ccs, you should bill Medicare for 95165 x 5 and 95115. Because Medicare interprets a billable dose as the amount of maintenance concentrate contained in the vile, you should report one unit per cc or five units of 95165. "You may not bill for dilutions of the maintenance concentrate," Atwater says.

For all other carriers, the clinical dose definition applies, the AAOA states. Therefore, if you incorrectly assume that all payers follow Medicare's definition of 95165, you will forfeit the reimbursement for the clinical dose. Suppose you bill the above example to a third-party payer that follows the drawn-up definition, but instead use Medicare's cc formula. The error will cost your practice $9.93 per unit (95165 contains 0.27 nonfacility relative value units based on the Medicare Physician Fee Schedule). That means you will lose a total of $49.65 for the five additional units, assuming that the commercial plan's conversion factor is the same as Medicare's ($36.79). Because most private insurers pay more than Medicare, the incorrect billing will probably cost more.

To make sure that you bill the correct amounts to each payer, write a procedure policy that explains your dose system, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "Flag Medicare charts and vials to make sure that you're using the right method."
 
Chart Must Show Immunotherapy Medical Necessity

 Improper billing methods can open the door to the OIG's finding a host of other 95165-related problems that you can avoid by encouraging your FP to improve documentation. The "Medicare Antigen Preparation" survey also states that many charts lack proper medical-necessity documentation for 95165. "The OIG is concerned about the potential for overprescribing immunotherapy," Callaway says. Therefore, it wants documentation to prove that the patient had year-round allergies and not just an occasional runny nose.

"Your FP, however, does not need to document the reason for immunotherapy every time he bills 95165," Callaway says. The chart should instead note that the patient's allergy testing results indicated that immunotherapy was necessary.
 
Note the Supervising Physician

Most important, your practice needs to follow Medicare's direct-supervision requirements for 95165. In contrast, the OIG's survey found that many FPs were billing for antigen preparation services performed in the absence of the supervising physician. If an auxiliary staff member, such as a registered nurse or technician, prepares the antigens, the FP must provide direct personal supervision of the services for the employee to bill 95165 incident-to the physician based on Medicare incident-to rules, Cobuzzi says.

Direct supervision does not mean that the FP must be in the same room when an NPP or aide prepares the antigens. But the physician must be present in the office suite and immediately available to provide direction and assistance throughout the time the staff person is performing the service, according to the Medicare Carriers Manual sections 2050.1-2050.2.

To substantiate that your office meets the supervision requirements, Empire Medicare suggests that whenever you bill services incident-to a physician, you should note that "Dr. Smith is here supervising," Cobuzzi says. "That way, Medicare doesn't have to go through your appointment books to make sure the doctor is present during the hours the technician is mixing the antigens."

Note: To view the OIG's survey, visit the Web site www.oig.hhs.gov/oei/reports/oei-09-00-00530.pdf.