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Wiki Allergy/Immunology
- Thread starter karenw
- Start date
ahumphrey,
I am taking your offer here. Please help me with the definition of "dose" on the CPT 95165.
Correct me if I am wrong; my interpretation of the dose is literally equal to "number(s)" of injections as the 2002 CPT Changes: An Insider's View defines a dose as "For allergy immunotherapy reporting purposes, the definition of a dose is the amount of antigen administered in a single injection from a multiple-dose vial, or drawn from a treatment board in one syringe. This will allow accurate reporting for the preparation and supply of each vial of antigen." and the April 2000, page 4, CPT Assistant Archives Coding Clarification indicate similiar definition: "For allergy immunotherapy reporting purposes, the definition of a dose is the amount of antigen administered in a single injection from a multiple dose vial, or drawn from a treatment board in one syringe."
With that said, if a patient received three injections (antigens drawn from a treatment board), then, the unit of 95165 should be listed as "three" as three injection constitutes 3 doses. Is that correct?
Thank you in advance for your help.
I am taking your offer here. Please help me with the definition of "dose" on the CPT 95165.
Correct me if I am wrong; my interpretation of the dose is literally equal to "number(s)" of injections as the 2002 CPT Changes: An Insider's View defines a dose as "For allergy immunotherapy reporting purposes, the definition of a dose is the amount of antigen administered in a single injection from a multiple-dose vial, or drawn from a treatment board in one syringe. This will allow accurate reporting for the preparation and supply of each vial of antigen." and the April 2000, page 4, CPT Assistant Archives Coding Clarification indicate similiar definition: "For allergy immunotherapy reporting purposes, the definition of a dose is the amount of antigen administered in a single injection from a multiple dose vial, or drawn from a treatment board in one syringe."
With that said, if a patient received three injections (antigens drawn from a treatment board), then, the unit of 95165 should be listed as "three" as three injection constitutes 3 doses. Is that correct?
Thank you in advance for your help.
The definition of "dose" for that code is how many cc you are billing for. If you had a 5 cc multi dose vial prepared you would bill for 10 doses. If it is a 10 cc multi dose vial you would bill for 20 doses and times it by how many vials the patient has. For instance if a patient has three 5 cc multi dose vials you would bill for 30 doses regardless of how many injections you get out of the vial.
The exception to this rule is Medicare patients. Medicare states that you can only bill for how many cc you prepare. So if you make a 5 cc multi dose vial you bill for 5 cc and same for 10 cc multi dose vials you would only bill for 10 cc. So if a patient has three 5 cc vials you would only bill for 15 doses. We make our Medicare and Blue Cross patients 10 cc vials once they hit maintence formula, not sure how your allergy clinic works but I would check with them on this as some bcbs plans only allow a certain number a doses billed in a year. I am not sure what you mean by treatment board as we do not use them we make everyone multi dose vials for their therapy.
Hope this helps
The exception to this rule is Medicare patients. Medicare states that you can only bill for how many cc you prepare. So if you make a 5 cc multi dose vial you bill for 5 cc and same for 10 cc multi dose vials you would only bill for 10 cc. So if a patient has three 5 cc vials you would only bill for 15 doses. We make our Medicare and Blue Cross patients 10 cc vials once they hit maintence formula, not sure how your allergy clinic works but I would check with them on this as some bcbs plans only allow a certain number a doses billed in a year. I am not sure what you mean by treatment board as we do not use them we make everyone multi dose vials for their therapy.
Hope this helps
Karenw,
I will say it's depending on the local policy and patient populations and I believe you are on the right track by billing per injection for the preparation of antigens 95165, for the off the board, if patients population is non medicare, because individual doses are prepared for patients when they arrive for their shot whereas prepared vials usually include multiple doses. However, if patients are on medicare, then, you may want to check CMS guidelines because CMS definition of a dose is based on 1 cc aliquot.
There are some carriers who have no written policy on the allergy treatment . When I encounter those carriers, to be conservative, I refer to the AMA definition of dose - the amount of antigen drawn from a treatment board in one syringe.
I could be wrong, but, I am sticking to this definition for now.
I will say it's depending on the local policy and patient populations and I believe you are on the right track by billing per injection for the preparation of antigens 95165, for the off the board, if patients population is non medicare, because individual doses are prepared for patients when they arrive for their shot whereas prepared vials usually include multiple doses. However, if patients are on medicare, then, you may want to check CMS guidelines because CMS definition of a dose is based on 1 cc aliquot.
There are some carriers who have no written policy on the allergy treatment . When I encounter those carriers, to be conservative, I refer to the AMA definition of dose - the amount of antigen drawn from a treatment board in one syringe.
I could be wrong, but, I am sticking to this definition for now.
This is from the CMS manual on one cc being one dose, remember this is for Medicare patients only.
"Code 95165 Doses. - Code 95165 represents preparation of vials of non-venom antigens. As in the case of venoms, some non-venom antigens cannot be mixed together, i.e., they must be prepared in separate vials. An example of this is mold and pollen. Therefore, some patients will be injected at one time from one vial – containing in one mixture all of the appropriate antigens – while other patients will be injected at one time from more than one vial. In establishing the practice expense component for mixing a multidose vial of antigens, we observed that the most common practice was to prepare a 10 cc vial; we also observed that the most common use was to remove aliquots with a volume of 1 cc. Our PE computations were based on those facts. Therefore, a physician’s removing 10 1cc aliquot doses captures the entire PE component for the service.
This does not mean that the physician must remove 1 cc aliquot doses from a multidose vial. It means that the practice expenses payable for the preparation of a 10cc vial remain the same irrespective of the size or number of aliquots removed from the vial. Therefore, a physician may not bill this vial preparation code for more than 10 doses per vial; paying more than 10 doses per multidose vial would significantly overpay the practice expense component attributable to this service. (Note that this code does not include the injection of antigen(s); injection of antigen(s) is separately billable.)
When a multidose vial contains less than 10cc, physicians should bill Medicare for the number of 1 cc aliquots that may be removed from the vial. That is, a physician may bill Medicare up to a maximum of 10 doses per multidose vial, but should bill Medicare for fewer than 10 doses per vial when there is less than 10cc in the vial.
If it is medically necessary, physicians may bill Medicare for preparation of more than one multidose vial.
EXAMPLES:
(1) If a 10cc multidose vial is filled to 6cc with antigen, the physician may bill Medicare for 6 doses since six 1cc aliquots may be removed from the vial.
If a 5cc multidose vial is filled completely, the physician may bill Medicare for 5 doses for this vial.
(3) If a physician removes ½ cc aliquots from a 10cc multidose vial for a total of 20 doses from one vial, he/she may only bill Medicare for 10 doses. Billing for more than 10 doses would mean that Medicare is overpaying for the practice expense of making the vial.
(4) If a physician prepares two 10cc multidose vials, he/she may bill Medicare for 20 doses. However, he/she may remove aliquots of any amount from those vials. For example, the physician may remove ½ aliquots from one vial, and 1cc aliquots from the other vial, but may bill no more than a total of 20 doses.
(5) If a physician prepares a 20cc multidose vial, he/she may bill Medicare for 20 doses, since the practice expense is calculated based on the physician’s removing 1cc
aliquots from a vial. If a physician removes 2cc aliquots from this vial, thus getting only 10 doses, he/she may nonetheless bill Medicare for 20 doses because the PE for 20 doses reflects the actual practice expense of preparing the vial.
(6) If a physician prepares a 5cc multidose vial, he may bill Medicare for 5 doses, based on the way that the practice expense component is calculated. However, if the physician removes ten ½ cc aliquots from the vial, he/she may still bill only 5 doses because the practice expense of preparing the vial is the same, without regard to the number of additional doses that are removed from the vial."
"Code 95165 Doses. - Code 95165 represents preparation of vials of non-venom antigens. As in the case of venoms, some non-venom antigens cannot be mixed together, i.e., they must be prepared in separate vials. An example of this is mold and pollen. Therefore, some patients will be injected at one time from one vial – containing in one mixture all of the appropriate antigens – while other patients will be injected at one time from more than one vial. In establishing the practice expense component for mixing a multidose vial of antigens, we observed that the most common practice was to prepare a 10 cc vial; we also observed that the most common use was to remove aliquots with a volume of 1 cc. Our PE computations were based on those facts. Therefore, a physician’s removing 10 1cc aliquot doses captures the entire PE component for the service.
This does not mean that the physician must remove 1 cc aliquot doses from a multidose vial. It means that the practice expenses payable for the preparation of a 10cc vial remain the same irrespective of the size or number of aliquots removed from the vial. Therefore, a physician may not bill this vial preparation code for more than 10 doses per vial; paying more than 10 doses per multidose vial would significantly overpay the practice expense component attributable to this service. (Note that this code does not include the injection of antigen(s); injection of antigen(s) is separately billable.)
When a multidose vial contains less than 10cc, physicians should bill Medicare for the number of 1 cc aliquots that may be removed from the vial. That is, a physician may bill Medicare up to a maximum of 10 doses per multidose vial, but should bill Medicare for fewer than 10 doses per vial when there is less than 10cc in the vial.
If it is medically necessary, physicians may bill Medicare for preparation of more than one multidose vial.
EXAMPLES:
(1) If a 10cc multidose vial is filled to 6cc with antigen, the physician may bill Medicare for 6 doses since six 1cc aliquots may be removed from the vial.
If a 5cc multidose vial is filled completely, the physician may bill Medicare for 5 doses for this vial.
(3) If a physician removes ½ cc aliquots from a 10cc multidose vial for a total of 20 doses from one vial, he/she may only bill Medicare for 10 doses. Billing for more than 10 doses would mean that Medicare is overpaying for the practice expense of making the vial.
(4) If a physician prepares two 10cc multidose vials, he/she may bill Medicare for 20 doses. However, he/she may remove aliquots of any amount from those vials. For example, the physician may remove ½ aliquots from one vial, and 1cc aliquots from the other vial, but may bill no more than a total of 20 doses.
(5) If a physician prepares a 20cc multidose vial, he/she may bill Medicare for 20 doses, since the practice expense is calculated based on the physician’s removing 1cc
aliquots from a vial. If a physician removes 2cc aliquots from this vial, thus getting only 10 doses, he/she may nonetheless bill Medicare for 20 doses because the PE for 20 doses reflects the actual practice expense of preparing the vial.
(6) If a physician prepares a 5cc multidose vial, he may bill Medicare for 5 doses, based on the way that the practice expense component is calculated. However, if the physician removes ten ½ cc aliquots from the vial, he/she may still bill only 5 doses because the practice expense of preparing the vial is the same, without regard to the number of additional doses that are removed from the vial."