shain.mastroianni@allergyasthmaclinicltd.com
Contributor
Optum is denying 95165 stating that this code requires an injection code or modifier. Anyone else seeing this denial? If so, what are you doing to get it processed & paid. Thank you in advance
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Wiki 95165 Denials
- Thread starter shain.mastroianni@allergyasthmaclinicltd.com
- Start date
lgardner
Guest
it looks like you need to add the administration
per EncoderPro (emphasis added by me):
These codes report the physician's preparation of an antigen for allergen immunotherapy and the provision of the antigen extract itself. These codes also include the providing physician's calculations for the concentration and volume to be used in the dosage based upon the patient's previous skin test results and personal history. These codes do not, however, include the administration of the allergen therapy. The number of doses must be specified and the vial(s) (series of vials from a treatment board or one multiple dose vial) from which the dose may be drawn is irrelevant. Report the code based on the type of preparation, i.e., the number of different venoms contained in a single administered injection of the extract. Report 95145 for a dose containing one single stinging insect venom, 95146 for an extract containing two single stinging insect venoms, 95147 for three, 95148 for four, and 95149 for five single stinging insect venoms in one dose extract. Code 95165 reports single or multiple antigens (not stinging insect), and 95170 is for a whole body extract of a biting insect or other arthropod.
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per CMS Billing and Coding Article: Allergy Immunotherapy:
To bill for 95165, the number of doses must be designated.
If a physician prepares the allergen and administers the injection on the same DOS, bill the appropriate injection code (CPT codes 95115 or 95117) AND the appropriate preparation (single dose) code (CPT codes 95145-95170). For billing, need to specify the number of doses in the days/units field
________________________________________________
and here is a cool article: CPT 95165 Coding Conundrums
per EncoderPro (emphasis added by me):
These codes report the physician's preparation of an antigen for allergen immunotherapy and the provision of the antigen extract itself. These codes also include the providing physician's calculations for the concentration and volume to be used in the dosage based upon the patient's previous skin test results and personal history. These codes do not, however, include the administration of the allergen therapy. The number of doses must be specified and the vial(s) (series of vials from a treatment board or one multiple dose vial) from which the dose may be drawn is irrelevant. Report the code based on the type of preparation, i.e., the number of different venoms contained in a single administered injection of the extract. Report 95145 for a dose containing one single stinging insect venom, 95146 for an extract containing two single stinging insect venoms, 95147 for three, 95148 for four, and 95149 for five single stinging insect venoms in one dose extract. Code 95165 reports single or multiple antigens (not stinging insect), and 95170 is for a whole body extract of a biting insect or other arthropod.
________________________
per CMS Billing and Coding Article: Allergy Immunotherapy:
To bill for 95165, the number of doses must be designated.
If a physician prepares the allergen and administers the injection on the same DOS, bill the appropriate injection code (CPT codes 95115 or 95117) AND the appropriate preparation (single dose) code (CPT codes 95145-95170). For billing, need to specify the number of doses in the days/units field
________________________________________________
and here is a cool article: CPT 95165 Coding Conundrums
shain.mastroianni@allergyasthmaclinicltd.com
Contributor
Good Morning 
Thank you for responding. So we don't do the injection on the same day we make the Serum/Antigen so it is only the Serum/Antigen code that we bill. How do I get my claims paid with only the 95165 billed?
Thank you for responding. So we don't do the injection on the same day we make the Serum/Antigen so it is only the Serum/Antigen code that we bill. How do I get my claims paid with only the 95165 billed?
lgardner
Guest
Hopefully someone who codes Allergy, will chime in, but per the LCD/coding article, it sounds like it cannot be billed separately.
wish I could be more help.
per the CMS billing and coding article:
Separate coding for injection only codes (i.e., codes 95115 and 95117) and/or the codes representing antigens and their preparation (i.e., codes 95144 through 95170) must be used.
If both services are provided both codes are billed.
This includes allergists who provide both services through the use of treatment boards.
wish I could be more help.
per the CMS billing and coding article:
Separate coding for injection only codes (i.e., codes 95115 and 95117) and/or the codes representing antigens and their preparation (i.e., codes 95144 through 95170) must be used.
If both services are provided both codes are billed.
This includes allergists who provide both services through the use of treatment boards.
shain.mastroianni@allergyasthmaclinicltd.com
Contributor
No I appreciate you!!!! Thank you so much! Yes, anyone with Allergy coding knowledge, please help me lol
lgardner
Guest
it's funny, because we have been asked to create "cheat sheets" for different specialties and I was assigned Pulmonary/Allergy.
so your question, gave me a head start.
shain.mastroianni@allergyasthmaclinicltd.com
Contributor
Yay!!! Good luck and hopefully I can ask you for help in the future
it's funny, because we have been asked to create "cheat sheets" for different specialties and I was assigned Pulmonary/Allergy.
so your question, gave me a head start.