Primary Care Coding Alert

Question: We have a patient who comes in regularly for allergy injections. Recently, we gave him the injections on the same date of service as an infusion for another condition. When we reported 95115 for the injection along with 96365 for the infusion, we were denied the 95115 with the explanation that it is bundled into 96365. Is there a way we can get paid for both services?

New Mexico Subscriber

Answer: Under Correct Coding Initiative (CCI) guidelines, 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection)  is bundled into 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour).

The good news in this scenario, however, is that you will be able to use a modifier to unbundle the procedures, as 95115 is a column two code for 96365 with a modifier indicator of 1. So, you can override the edit by appending either modifier 59 (Distinct procedural service), XU (Unusual non-overlapping service), or possibly XS (Separate structure) to the 95115, depending on payer preference, to appeal the denial.