Wiki Preparation of sublingual allergy drops?

[jvanbk]

Hello,
I am new to allergy-related coding. We bill 95165 for the preparation of allergy vials for injection. Can 95165 also be billed for the preparation of allergy serum for sublingual drops? This clinic has been billing 95199 for the preparation of the drops and the patient self-paying.

Please let me know what has worked for everyone else?

Thank you!

Jennifer

 

[JenniferB7]

The code 95165 is preparation for an injection, not sublingual drops. The correct code is 95199 (unlisted) and most payers consider this to be non-covered/experimental, in which case it is appropriate to charge the patient at self-pay rates.

Hope that helps.

Jennifer M. Connell, CPC, CPCO, CPC-P, CPB, CPMA, CPPM, CPC-I, CENTC

 

[jvanbk]

Thank you very much for your feedback! One of our patients called his insurance, Humana, and said that they do pay for sublingual drops but denied our claim with 95199 and accompanying records because we "did not bill with the correct code". So I am trying to figure out which code Humana would have expected us to bill with. I think I will try calling them to ask, but it will be like finding a needle in a haystack, I'm afraid.

The code 95165 is preparation for an injection, not sublingual drops. The correct code is 95199 (unlisted) and most payers consider this to be non-covered/experimental, in which case it is appropriate to charge the patient at self-pay rates.

Hope that helps.

Jennifer M. Connell, CPC, CPCO, CPC-P, CPB, CPMA, CPPM, CPC-I, CENTC

 

[JenniferB7]

Thank you very much for your feedback! One of our patients called his insurance, Humana, and said that they do pay for sublingual drops but denied our claim with 95199 and accompanying records because we "did not bill with the correct code". So I am trying to figure out which code Humana would have expected us to bill with. I think I will try calling them to ask, but it will be like finding a needle in a haystack, I'm afraid.

You might find this helpful. I looked at Humana's medical policies.

Medical Policy: View attachment Allergy Treatments.pdf​

Pharmacy Policy: View attachment Sublingual Grass Pollen Allergen Extract.pdf​

Under the medical policy, is clearly states that sublingual therapy is a "coverage limitation" and is considered experimental/investigational. However, sublingual drops appear to be covered as a pharmacy benefit (see pharmacy policy), provided that the patient meets specific criteria and you obtain prior authorization. So, it looks like it is covered as a prescribed medication that the patient self-administers, but not covered as a service performed in the doctor's office. I would certainly reach out to Humana and / or your Humana Provider Representative as these are their general policies and the patient's specific benefit plan may have different language.

Hope that helps,

Jennifer M. Connell, CPC, CPCO, CPC-P, CPB, CPMA, CPPM, CPC-I, CENTC