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Pulmonology Coding Alert

Reader Question:

Allergen Immunotherapy

Published on Mon Oct 01, 2001

Question: How can we get paid for two or more allergy injections (different medications) with 95125 (professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; two or more injections) and 95117 (... not including provision of allergenic extracts; two or more injections)? I can get paid for only one injection at a time.

Nevada Subscriber
 
Answer: Effective Jan. 1, 1995, pulmonologists and allergists must identify and report each provided service (allergen preparation/provision and administration) separately.  
 
CMS recognizes 95115 (professional services for allergen immunotherapy not including provision of allergenic extracts; single injection), 95117 and 95144-95170 (codes representing antigens and their preparation).
 
If your physician provides both the injection and the antigen or prepares the antigen, select one code for the injection/administration (95115 or 95117) and one code from 95144-95170 for the antigen preparation and provision. 
 
According to the Medicare Carriers Manual Section 15050B.3, single-dose vials are used to ensure proper dosages for the injection. They cost more and are reimbursed at a higher rate. Allergists who prepare and provide antigens should be able to do so from the cost-efficient, multidose vials. Thus, Medicare instructs billing 95165 (professional services for the supervision and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]) for antigen preparation and provision instead of 95144 when reporting this service with the administration, 95115 or 95117.
 
Whether a single- or multidose vial is used or reported, Medicare will  reimburse only for the multidose vial rate, i.e., 95165. Medicare pays for 95144 only when the antigen is prepared for injection by another entity. 
 
The fee schedule amounts for 95144-95170 are for a single dose. When billing these codes, physicians should specify the number of doses provided. CMS Program Memo B-00-53 has identified a "dose" as a 1-cc aliquot from a multidose vial, and the limitation for potency of the allergen extract as 12 months. It instructs carriers to multiply the fee schedule amount by the number of doses specified in the units field. 
 
If a physician only provides the administration of the allergen, report 95115 or 95117 as appropriate. Administration services differ from provision/preparation services in that the administration codes are reported  only once per patient encounter.
 
-- Answers to You Be the Coder and Reader Questions provided by Carol Pohlig RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania in Philadelphia; Melissa Kersnick, CPC, Stoler and Horowitz, Louisville, Ky; and Walter O'Donohue, MD, FCCP, FACP, chairman of the CPT committee of the American College of Chest Physicians (ACCP) and a representative to the AMA CPT advisory committee for ACCP

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