Primary Care Coding Alert

Family practice coders turning to the allergen immunotherapy section of the CPT manual often express frustration with the long list of codes that may be assigned to patients receiving allergy shots. This portion of the manual encompasses codes 95115-95199, with descriptions so similar that coders may be unclear about which code to report. Once a coder understands the rationale for the codes and which are considered payable, it becomes more clear when each is used, says Cynthia DeVries, RN, BSN, CPC, a coding and reimbursement coordinator for Lee Physicians Group, a 140-provider multispecialty practice in Fort Myers, Fla.

It seems like there are too many codes to choose from, she contends. But, in reality, many are not recognized or paid by insurance carriers.

The multitude of codes is a result of a 1995 Health Care Financing Administration (HCFA) decision to unbundle allergen immunotherapy services, which specifically affects codes 99115-99170, DeVries adds. Previously, coders would use one code to report both the preparation of the allergy serum and the administration of the injection. Now, however, physicians and coders must list each service separately, giving practices more reimbursement opportunities.

Coding Allergen Immunotherapy Injections

When HCFA unbundled the allergy codes five years ago, it assigned just two codes for injection services:

95115 professional services for allergen immunotherapy not including provision of allergenic extracts; single injection; and

95117 professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections.

These two codes should be reported for the injection only and do not include the extracts, points out Laura Pettigrew, RHIA, CPC, CCS-P, a training and auditing coordinator for Methodist Medical Group, which provides coding services to 96 physicians in the Indianapolis area. These codes would be assigned in cases where a patient has seen an allergist who makes up the antigen, prepares the vials and provides the antigen to the family practice for injection. Coders for the family physician would assign 95115 for one shot or 95117 for multiple shots.

Note: Many family physicians require that they see the patient at least one time prior to administering allergy immunotherapy to document the need for the shots.

Besides reimbursement for the injection itself, DeVries adds, these two codes include 30 minutes of nurse time to monitor for a reaction. Even though a patient may have received an uneventful allergy shot hundreds of times before, he or she suddenly may develop a reaction. It is imperative that a patient is monitored after each injection and these codes take that time into consideration.

Practices would not add an evaluation and management (E/M) code to the patients visit, Pettigrew notes. Although a physician must be on-site when a patient receives an allergy injection, you wouldnt assign an E/M code unless there is a separately identifiable service being provided. Practices often wonder about reporting the so-called nurse visit code, 99211 (office or other outpatient visit for the evaluation and management of an established patient with minimal presenting problems), but 95115 and 95117 are designed to include nurse interaction with the patient.

Assign E/M Codes Only for Separate Services

One exception to this may arise when an established patient comes in for a preventive visit (99391-99397) or an outpatient visit for a specific problem (99211-99215), and receives an allergy shot on the same day. In addition, some physicians will see the patient 15 minutes after the shot if the injection is being taken from a new vial or includes a new extract. This typically would be coded 99212 (office or outpatient visit for the evaluation and management of an established patient, which requires a problem-focused history and examination and straightforward medical decision-making), and allows the physician to evaluate the patients reaction.

Another exception occurs when a patient has an adverse reaction to the injection, Pettigrew says. In that instance, the physician will see the patient to evaluate the severity of the symptoms and prescribe the appropriate treatment. The proper E/M code then would be assigned, depending on the level of service (99212-99215). In many instances, 99214 or 99215 most accurately would describe the care provided because this is considered a life-threatening condition and would meet the criteria for high complexity decision-making. As always, documentation must support the level of visit that is coded.

Example: A 15-year-old male received his weekly allergen immunotherapy injection but experienced a moderately severe anaphylactic reaction. He is treated with an epinephrine injection, followed by IV Benedryl and IV fluids, and is monitored in the office for 45 minutes. The practice would report codes 95115 for the allergy injection and 99214 for the problem-focused office visit. Coders also may assign 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) for the administration of the Benedryl and fluids. The epinephrine injection would be included in the E/M service.

Coders should append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to indicate that treatment for the adverse reaction is a separate service from the administration of the allergy shot. In addition, they also may report the provision of the medications. In this case, these include J1200 (injection, diphenhydramine HCI, up to 50 mg) for the Benedryl and J0170 (injection, adrenalin, epinephrine, up to 1 ml ampule) for the epinephrine.

Coding for the Provision of Antigen

Although 95115 and 95117 describe only the injection services, the remaining codes in the allergen immuno-therapy section of CPT define the provision of the allergenic extracts (95120-95170), Pettigrew says. The majority of these do not include the injection services and most often will be reported by allergists who specialize in preparing the antigen, although some family physicians also are involved in this area.

95120-95134: Often Not Payable

Codes 95120-95134 continue to appear in the CPT manual and describe the entire process of preparing, providing and administering the serum in a patient encounter. DeVries points out that Medicare and many other payers no longer accept these codes and view them as nonpayable. Most insurers now require that two codes one representing the provision of the antigen and one describing the injection be reported instead of a single service code, she says.

Many local Medicare carriers, including Palmetto G.B.A. in South Carolina, HGS Administrators in Pennsylvania, WPS in Wisconsin and Empire in New Jersey and New York, deny these charges because they represent bundled services. For instance, WPSs guidelines for Wisconsin state These codes will no longer be recognized for payment purposes. The physician providing both components of the service must now do component billing. They do not have the option of using a complete service code.

95144 and 95165: Single- and Multiple-dose Vials

Code 95144 (professional services for the supervision and provision of antigens for allergen immunotherapy; single or multiple antigens, single dose vials [specify number of vials]) is used to report regular antigens (other than stinging insects) and is assigned to the preparation of single-dose vials. Because it is more costly to provide the antigen in a single-dose vial, many payers have placed restrictions on how and when this code may be reported. In most cases, payers will reimburse only multi-dose vials.

The related code 95165 (professional services for the supervision and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]) is used to report multiple-dose vials of non-venom antigens.

Medicare seems to believe that a specialist preparing antigens should have multiple-dose vials available, DeVries warns. I have seen many cases where coders have billed 95144, but the carrier changed the code to 95165 for payment.

95145-95149 and 95170: Stinging Insect Venoms

Codes 95145-95149 and 95170 are used to report antigen preparation for stinging insect venoms. Code 95145 describes professional services for the supervision and provision of antigens for allergen immunotherapy (specify number of doses); single stinging insect venom. Codes 95146-95149 would be assigned when two, three, four or five venoms, respectively, are included in the extract. Code 95170 describes professional services for the supervision and provision of antigens for allergen immunotherapy; whole body extract of biting insect or other arthropod (specify number of doses).

Coders should note that each of these codes specifies that the number of doses be recorded. According to the May 1996 CPT Assistant, however, coders should be aware that it doesnt matter whether the dose comes from a series of vials or a single multiple-dose vial because the code describes the dose, not the bottle from which it is drawn.

Note: Professional coders should check with their local carriers to determine the policy regarding these series of codes.