Pulmonology Coding Alert

Question: For our physician’s allergen immunotherapy services, we reported CPT^® code 95165 with 92 dosage units. The insurer paid for 30 units and denied the rest (62 units) since the benefit maximum had been reached.

Can you please tell me if 30 is the maximum units allowed per day, per month, or per year? I know Medicare pays for 10 units a day and we can bill consecutive days until we reach the total units.

Wisconsin Subscriber

Answer: Code 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)) has a medically unlikely edit (MUE) of 30, which means you can only 30 units of this code on a given date of service.

An MUE for a HCPCS Level II/CPT^® code is the maximum units of service (UOS) allowed under most circumstances by the same provider for the same beneficiary on the same date of service. The ideal MUE value for a code is the unit of service that allows the vast majority of appropriately coded claims to pass the MUE.

Keep in mind: Private payers may have different benefit coverage determinations where maximum benefits are concerned.

The Medicare Benefit Policy Manual indicates that, “Antigens must be administered in accordance with the plan of treatment and by a doctor of medicine or osteopathy or by a properly instructed person (who could be the patient) under the supervision of the doctor. The associations of allergists that CMS consulted advised that a reasonable supply of antigens is considered to be not more than a 12-month supply of antigens that has been prepared for a particular patient at any one time. The purpose of the reasonable supply limitation is to assure that the antigens retain their potency and effectiveness over the period in which they are to be administered to the patient.”

Limitations: Medicare only allows a physician to report 10 cc doses/units per prepared vial, regardless of the amount of antigen to be injected each time. Medicare, through MUEs, has determined that a physician would likely not prepare more than three vials at one time. 

Build-up: Since allergy injections are typically not given on consecutive days, three vials could last significantly more than three months, depending upon whether the patient is in the build-up phase or the maintenance phase. The build-up phase includes the initiation and subsequent rise of applicable antigen concentrations. Documentation of this phase should include:

• The initial concentration
• Any changes/delay of progress and the reasoning for such delays
• The target concentration.

In contrast: In the maintenance phase, the injections become few and far between. In order to prevent payment for prescriptions that may not be used due to changes in the regime or unexpected patient issues, payers place a frequency limitation or maximum benefit during a given time frame.

More guidance: Consider this additional instruction, outlined in the Novitas LCD 36240:

• The supervising physician should be documented in the medical record.
• The physician must have examined the patient and determined a plan of treatment and a dosage regimen.
• Injections usually occur one to three times per week and can take anywhere from eight-28 weeks to achieve a maintenance dose.
• Various techniques such as cluster immunotherapy and rush immunotherapy are also included in the build-up phase and should be documented as such in the medical records. These techniques are noted to have more frequent injections in the build-up phase.

In the Maintenance Dose Interval, the frequency of maintenance dosing can be variable depending on the extract used. During the first year, frequency may vary from subsequent years. The Task Force notes for some antigens, the maintenance dose could be every four-eight weeks. However, the frequency should be at least every two weeks for this dosing.