Wiki 95165 Allergy Immunotherapy Unit Denials

[karimbra]

Anyone else having a problem with 95165 reimbursements for vial prep with Medicaid? Specifically, Wellcare. We are told that this has been happening nationally. Previously, we were reimbursed for 2 vials of 10 units each (mold vial and pollen vial). Now they are denying 10 units. So far, the only explanation we have been given is we cannot claim more than 10 units per day. We have several denials we would like to appeal if anyone has any input or success with this.

 

[Wiethoff]

Definition of a Dose

Please see below definition of a dose per Medicare guidelines:

Allergen Immunotherapy (Medicare excerpts)
Billing Guidelines:
CPT procedure code 95165 is used to report multiple dose vials of non-venom antigens. Effective January
1, 2001, for CPT code 95165, a dose is now defined as a one- (1) cc aliquot from a single multidose vial.
When billing code 95165, providers should report the number of units representing the number of 1 cc
doses being prepared.

If your vial containes 10 ml/cc and you administer 20 x .5 cc doses you still only bill for 10 doses. If your vial containes 5 ml/cc total than you only charge for 5 doses.

Hope this helps.

 

[Wiethoff]

Vial Size

Anyone else having a problem with 95165 reimbursements for vial prep with Medicaid? Specifically, Wellcare. We are told that this has been happening nationally. Previously, we were reimbursed for 2 vials of 10 units each (mold vial and pollen vial). Now they are denying 10 units. So far, the only explanation we have been given is we cannot claim more than 10 units per day. We have several denials we would like to appeal if anyone has any input or success with this.

How many cc/ml are in each of your vials? The total cc/ml in each vial is the unit quantity to bill.