Dose Counts Matter When Billing 95165
- By admin aapc
- In CMS
- June 1, 2009
- 17 Comments
Is your practice billing the number of services for Allergy Immunotherapy CPT® code 95165 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) correctly? The Comprehensive Error Rate Testing (CERT) Payment Safeguard contractor, AdvanceMed, seems to think not, and has put Medicare contractors on the alert.
Report CPT® code 95165 for preparation of multidose vials of non-venom antigens in addition to the appropriate injection code(s).
When reporting 95165, however, be careful how you count doses. According to the Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sect. 200.B.7, “a physician’s removing 10 1 cc aliquot doses [from a 10 cc vial] captures the entire PE [practice expense] component for the service.”
The practice expense payable for the preparation of a vial remains the same regardless of the size or number of aliquots removed from it. Report CPT® 95165 for no more than the total number of doses contained in the vial. Reporting the correct number of doses ensures proper payment.
For example, if a physician prepares a 10 cc multidose vial and removes ½ cc aliquots for a total of 20 doses, the most you can bill Medicare for is 10 doses.
Likewise, if a physician prepares a 20 cc multidose vial and removes 2 cc aliquots for a total of 10 doses, you should bill Medicare for 20 doses. Reporting only 10 doses would result in an underpayment to the practice.
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To clarify the service, CMS would be advised to work with the AMA to change the descriptor of the code to specify number of CCs, rather than specify number of doses, or this confusion will undoubtedly continue.
Also, the question on the Test Yourself is awkwardly worded — it appears to state that twenty and one-half ccs were removed from a 10 cc vial, which is physically impossible, rather than the likely intended 20 times 1/2 cc doses.
I agree, and regarding the test question.
Does the 1cc “aliquot” include diluent? ie. If you mix .2cc of each antigen and add appropriate amount of diluent to make a total volume of 5cc. Would you bill 5cc or the actual amount of concentrate included?
It seems that Medicare is only allowing 10units per line for 95165. If the doctor is billing 40 allergy preparations how do you bill this. I tried putting 40 in the units box and the claim rejected. I then tried putting 4 lines each with 10 in the unit box and used modifier 51 for multiple procedure. This failed as well. What is the correct way to bill this?
I’ve seen where the physician is billing 150 doses. So confused. help?
The confusion will remain until CPT changes the description of the code to reflect 1cc=1dose.
in my search I found this:
Effective January 1, 2001, for CPT code 95165, a dose is now defined as a one-(1) cc aliquot from a single multidose vial.
If this is the case then CPT needs to jump on the train and catch up the code and allow for this wording. The confusion would stop.
Per Medicare guidelines, they will only pay up to 30 units at a time.
Where can I find these guidelines that state 30 units? I’ve searched everywhere and it only says 10 units. Also, is this 30 units per day or 30 units per month?
Can a physician bill for 95165 if they outsource the mixing and pay for the mixing? Or does the mixing need to be performed by the physician who is administering the Immunotherapy?
Please advise.
If a physician prepares 75 units what is the appropriate way to submit this to Medicare!! Please help 🙁
you can bill up to 10 units per DOS….. so if you have 75 units to bill, you would bill 10 units per day until you equal the amount of units to be paid.
Angela,
I’m new to allergy billing and doing a lot of research. Can you direct me on where I can find the documentation to back up your answer? Thank you!
If you prepare 50 units of 95165 ,do you submit a claim for dos 10/1/17 (30 units) and bill the remaining units 20 days later or
the following month?
Where is this documentation. Is this compliant?
We use a 5 ml vial for allergy serum. If I am understanding this thread, I would charge Medicare for 5 doses per vial (at 1 cc each). What about the commercial carriers? We normally bill 14 doses per vial. Any assistance or documentation you can provide is greatly appreciated. Thank you.
If a multi-dose vial is not prepared, but the physician pulls ‘off the board’ for the injection to be given that day; how is the preparation billed?
https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34597_9/L34597_ALRG001_BCG.pdf
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. A maximum of 10 doses per vial is allowed for Medicare billing, even if more than
ten preparations are obtained from the vial. In cases where a multidose vial is diluted, Medicare should
not be billed for diluted preparations in excess of the 10 doses per vial allowed under code 95165.
CPT procedure codes 95145-95149 and 95170 are used to report stinging insect venoms. Venom doses
are prepared in separate vials and not mixed together -except in the case of the three vespid mix (white
and yellow hornets and yellow jackets). Use the code within the range that is appropriate to the number
of venoms provided. If a code for more than one venom is reported, some amount of each of the venoms
must be provided. Use of a code below the venom treatment number for the particular patient should
occur only for the purpose of “catching up.”
When a venom regimen requires that antigens be mixed from more than one vial for administration and,
due to a dose adjustment of one of the antigens, one vial is depleted before the other, the physician may
bill for “catch-up” doses of the short antigen. This must be done in a manner that synchronizes the
preparation back to the highest venom code possible in the shortest amount of time. To catch up, the
physician would bill only the amount of the depleted vial needed to catch-up with the other vials. This will
permit the physician to get back to preparing the full number of venoms at one time and billing the doses
of the “cheaper” higher venom codes. Use of a code below the venom treatment number for the
particular patient should occur only for the purpose of “catching up.”
The antigen codes (95144-95170) are considered single dose codes. To report these codes, specify the
number of doses provided.
If a patient’s doses are adjusted (e.g., due to reaction), and the antigen provided is actually more or
fewer doses than originally anticipated, make no change in the number of doses billed. Report the number
of doses actually anticipated at the time of the antigen prepara
My issue with the Medicare excerpts is that it says; “Medicare should not be billed for diluted preparations in excess of the 10 doses per vial allowed under code 95165”. How I read this is, “you can bill Medicare for diluted preparations but you can’t bill for more than 10 doses per vial (if the vial is 10cc)”, a lot of the 3rd part training references take this as “you can’t bill for diluted vials”. What are your thoughts?