Pulmonology Coding Alert

Vital: Learn when you can include an E/M service.

Coding your pulmonologist's allergy immunotherapy services can be arduous if you aren't up to speed on how to handle injection-only codes and those for antigen preparation. Our expert guidance that follows makes your task easier as we take you through the ins and outs of billing for allergy immunotherapy.

Turn to These Codes for Injections Only

When your pulmonologist provides only the injections for the allergy immunotherapy and the allergenic extracts for the injections came from another source, you should code for the injections only, depending on the number of injections provided. If your pulmonologist provided only one injection, reach for CPT® code 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection).

If your pulmonologist provides more than one injection, use 95117 (Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections) to report the allergy immunotherapy services that your pulmonologist performed. "The code involves the observation service (to check for allergic reactions) that your pulmonologist performed after the injection," says Mary I Falbo, MBA, CPC, President of Millennium Healthcare Consulting, Inc., Lansdale, PA. "Keep in mind that these codes only represent the administration of the extract prepared by your pulmonologist or someone from your facility."

Reminder: If your pulmonologist administered the antigens sublingually (i.e., by placing drops under the patient's tongue), then you cannot claim reimbursement for the service. Note that antigen(s) administration is covered only if it is injected by your pulmonologist, a licensed non-physician provider or a qualified nurse (under the supervision of your pulmonologist).

Apply These Administration and Prep Codes

"When your pulmonologist is directly involved in the preparation of the antigen and furthermore he gives the immunotherapy, then you must report the services using CPT® code 95120 (Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; single injection) for single injections," says Falbo.

If your pulmonologist provides two or more injections along with preparing the allergenic extracts that he is administering to the patient, you will have to use 95125 (Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; 2 or more injections) instead of 95120.

Caveat: "Keep in mind that these codes are not valid for Medicare and those that follow Medicare rules," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia. "Medicare uses other codes to capture and reimburse preparation and provision of allergen extract services."

Know the Codes for Allergenic Extract Preparations

Along with knowing the codes to report injections-only, you'll best capture your provider's services for allergenic extract prep if you apply the appropriate code. Most payers recognize 95144 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose vial[s] [specify number of vials]) or 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]) to report the provision of the allergenic extracts, whether the allergenic extracts are mixed or prepared by a person of another facility or by the same individual providing the injections.

"Be sure to report the correct code, dependent upon whether or not single dose vials are prepared, or the more common multi-dose vial," advises Pohlig. "For single dose vials, report the total number of vials prepared for the patient. For multi-dose vials, report the number of 1cc doses prepared (even if the patient will not be given a 1cc dose at a given encounter)."

Example: Your pulmonologist prepares a 10cc multi-dose vial of allergenic extracts to be administered to a patient suffering from pollinosis. The patient is administered 1cc of the extracts from the multi-dose vial. You will have to report 95165 x 10 (for the extract preparation) and 95115 for the single injection administered.

Don't Forget to Report E/M Services When Performed

You may be unsure about reporting E/M services along with allergy immunotherapy codes. "The allergy administration codes include a pre-procedure evaluation to ensure that the patient is able to receive the injection and a post-procedure evaluation period to determine if the patient is in jeopardy of an allergic reaction, so one cannot report an E/M code unless a separate identifiable service is performed," says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. "Obtaining informed consent is included in the immunotherapy," adds Falbo.

Remember that you have to report the E/M services provided with an appropriate E/M code (such as 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient...) depending on the level of E/M services provided when a separate service is performed in addition to the allergy immunotherapy. Add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to help the payer know that a separate service has been performed in addition to the allergy immunotherapy. Include documentation of the separately identifiable service that has been performed.

Example: Your pulmonologist assesses a patient suffering from severe pain and fever due to a peritonsillar abscess (475), and the patient receives her scheduled bimonthly series of allergy immunotherapy for allergic rhinitis due to dander (477.2). Your pulmonologist performs and documents a level-three E/M service. You may report 99115 and 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components... Physicians typically spend 15 minutes face-to-face with the patient and/or family) along with the modifier 25 appended to 99213.