Pulmonology Coding Alert

Sometimes, the patient's doses are adjusted. If a patient has an adverse reaction to an antigen and the amount provided is more or less than that anticipated, the physician does not make a change in the number of doses for which he bills.

Remember that Medicare will only pay for a reasonable supply of antigens prepared for the patient. The antigens must be prepared by a physician who is a doctor of medicine or osteopathy and who examined the patient to determine a plan of treatment. A reasonable supply is considered to be no more than 12 weeks. Documentation must support the medical necessity, and proper ICD-9-CM codes must accompany the claim.

What should you do when you have to see a patient for an office visit and administer an injection? "You can code separately for the office visit when the patient is being seen for a condition other than receiving allergy injections," Jernigan says.

CPT reiterates this point that an office visit may be reported in addition to allergy immunotherapy only when other significant, identifiable services are provided during the visit. The significant services can include an examination of the patient, interval history, and the evaluation of diagnostic tests. You would need to use modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Jernigan offers the example of an asthma patient who comes in for a follow-up of management for asthma and receives an injection for allergic rhinitis at this time. You would add modifier -25 to the office visit code, such as 9921x-25. It is important to show a different diagnosis code related to the office visit as opposed to the allergy injection. For example, if the focus of the office visit is the discussion of prescription management for the asthma, then you would use diagnosis code V58.69 (Long-term [current] use of other medications) and 493.xx (Asthma) for the office visit and a code from the 477.x series (Allergic rhinitis) for the allergy injection. The documentation must show that the injection is separately identifiable from the office visit.

Often, a lab outside of the office of the administering physician creates an antigen for the physician to use.

Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, the president of Cash Flow Solutions Inc., in Lakewood, N. J., states that "many insurance companies separate prescription benefits from the physician office benefits." Therefore, if the lab makes the antigen and the doctor only writes the prescription, the prescription plan pays for the antigen. The preparation is not billable by the doctor.

Physicians often prepare antigens for direct administration by other doctors, such as primary-care physicians. An example given by Jernigan refers to a patient who lives in a rural area and finds it easier to receive the injections at his local primary-care physician's office. The pulmonologist would make the antigen and mail it to the physician's office. When the patient needs more serum, the primary-care physician would notify the pulmonologist. In this case the pulmonologist codes 95165 x the number of doses, and the primary-care physician codes 95115 or 95117 depending on how many injections are given.