Wiki Allergy antigen billing

[amsmith]

We are trying to make sure that we are billing correctly in our allergy department for the services that we are providing.

• The patient is examined in the Allergy Clinic by a licensed Allergist and subsequently allergy skin testing is performed if indicated.
• Based on the results of the skin testing, the Allergist determines that allergy immunotherapy injections are medically necessary to minimize allergy responses and the patient agrees to proceed with a series of allergy immunotherapy injections.
• The Allergist creates a prescription for allergy extract vials based on the patient’s responses to allergy testing. Each vial contains several antigens. There may be from 1 – 4 concentrated vials for the patient, depending on the range and type of allergies, along with several dilutions.
• The patient’s immunotherapy prescription is securely transmitted through a portal to a professional allergy immunotherapy compounding service.
• The patient’s antigen vials are compounded following USP 797 and all applicable guidelines. They have a board certified allergy/immunology specialist and a Pharm D on staff.
• The vials are received in the Allergy Clinic. The Allergy Clinic pays for the cost of the vials at $220 - $250/vial for a maximum of $880 - $1000 per patient if they have 4 vials.
• The antigen injections are given on a weekly basis in the Allergy Clinic by trained and licensed staff, with a supervising physician on site. We follow a structured build up, starting at 0.1 mL (cc) and increasing gradually to 0.5 cc, then to less dilute vials. We anticipate getting a minimum of 43 injections from one vial set.

Can we bill the 95165? There appears to be some confusion regarding "supervision of preparation" and the direct supervision requirements.

If not, we are open to any assistance available.

 

[Christal]

We bill the 95165 but we prepare our own antigen. I am not sure about billing that out since you do no prepare it. I do know when billing the antigen you bill for the number of cc in the vial. For example, if you prepare a 5 cc vial then you have 5 units. It does not matter how many injections you get out. The guidelines is the preparation of the vial 5cc or 10cc. For the injections you would bill 95115 for 1 injection or 95117 for 2 or more injections.

 

[mjspidey]

If your office did not prepare the vials, you cannot bill 95165. When the injection is administered by a trained member of your office, you are able to bill 95115 for a single injection or 95117 for 2 or more injections (since some antigens cannot be combined). Hope this helps!

 

[arichards@mhsystem.org]

We bill the 95165 but we prepare our own antigen. I am not sure about billing that out since you do no prepare it. I do know when billing the antigen you bill for the number of cc in the vial. For example, if you prepare a 5 cc vial then you have 5 units. It does not matter how many injections you get out. The guidelines is the preparation of the vial 5cc or 10cc. For the injections you would bill 95115 for 1 injection or 95117 for 2 or more injections.

Hello Christal,
Please help!!! I've been researching and researching and trying to figure out how bill 95165 out correctly. I recently took on Allergy office and the provider used to be private before joining our hospital, so she did her own billing and has explained to me how these are prepared (they mix in their office). I am questioning 2 things, if I'm billing out the correctly

1. Is it dosages or units of how much is antigen is prepared and
2. why the insurances are denying. I am aware that MCR and Medicaid's pay differently (no dilutions) see example below. Now for commerical where they accept 120 dosage per calendar year, do you normally have to split that up into multiple dos?

2 of these vials are filled with 5mls of serial dilutions of different antigens (I've attached my breakdown of how she is getting 66 doses).

With the dilutions=each vial can get 33 doses (based on how the provider demonstrated), so when preparing for 2 vials there is a total of 66 doses.

Since MCR only allows 10 doses per vial, with 2 vials it seems it should be billable for 20 dosages? -however since this office uses a 5ml vial looks like that changes how much to bill out so, it would only be 10 dosages? based on the below information. MCR allows up to 10 doses per vial, but based on mcr guidelines if provider uses a 5ml vs 10ml that reduces the number of doses..correct? please see my example below(took out any private/pt info)

Any help/guidance is very much appreciated!

 

[Christal]

Sorry for late response. I am no longer billing for allergy but the information I am giving is what we done in March. The answer to guestion 1. You bill the units made, not the number of injections you get. For example: if you mix a 5cc vial times 2 vials then you bill total 10 units. Prepare 3 10 ccs vials, you bill 30 units. Question 2. Some payers only allow 30 units a day to be billed, so for the most we billed 30 units one day and bill the rest the following day or so. If remember correctly Aetna we could bill more than 30 units a day. I hope this helps.

 

[arichards@mhsystem.org]

Yes! Thank you so much!!! when you are referring to the injections, you mean the doses correct? We bill for the units.... not the number of doses? How do you bill for commercial insurance situations, which do allow to bill for serial dilutions and based on when I spoke with my providers, she advised the serial dilutions are how they conclude how many doses there are. So for the example above say it's Aetna, Cigna or BCBS which allow to bill the serial dilutions which all together equal 66.
1. You would bill the 30 units, then next day bill 30, and then another 6 the following day...is that correct?

I keep questioning, because my provider used to do their own billing and when I spoke with her she advised she billed mcr/odhs the units without serial dilutions, but commercial insurance does allow to count the serial dilutions, which is why I think she was billing higher for those.

2. What I gather is the only way we would bill multiple days out would be if the provider mixed 7 vials or more, because my provider stated she only uses 5cc vials. This would be 5cc times 7 vials which is a total of 35 units. Which if it was: mcr/odhs= would be billed 4 times, 10units for 3 dates of service and then the remaining 5units on another date of service.
commerical=would be billed 2 times, 30 units on the first date of service and the remaining 5 units on the other date of service.


So first I need know if I am counting doses at all based on how the provider is documenting. (question 1 above)
Second do we bill for the serial dilutions? because from my understanding we can if commerical and that would allow for us to bill more units, up to 30units that day, even if only used a 5 cc vial time 2vials, but we could bill for serial dilutions that would be billing for the injections/doses. So that is why I am so confused!! PLEASE HELP! I've researched this a ton of times and keep coming back to this.