Primary Care Coding Alert

If you're billing incorrectly for 95165, you're not alone a recent survey found that 40 percent of physicians code this service incorrectly. These findings are prompting audits that are also targeting improper documentation and supervision, so make sure you fix your problems before the OIG and CMS start scrutinizing your billing practices.
 
Recently, the Office of the Inspector General (OIG) surveyed 600 ENT, general allergy and family practice offices that bill for allergy services to define how physicians interpret and bill 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]), according to the American Academy of Otolaryngic Allergy (AAOA) Coding Advisory. Because CPT and Medicare differ in how they define the dose specified in 95165, the survey discovered that 40 percent of physicians bill the code incorrectly. Therefore, you should pay close attention to the two billing methods for 95165. Bill Based on Payer-Defined Dose The AMA and CMS have two different definitions of a dose as defined in 95165. CPT defines a clinical dose as "the amount of antigen(s) administered in a single injection from a multiple-dose vial," says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "On the other hand, Medicare defines a billable dose, not a clinical dose, as 1 cc."

Although a physician may administer any amount of an antigen, based on clinical judgment, Medicare allows billing only the maintenance concentrate, says J. Spencer Atwater, MD, president of the Joint Council of Allergy, Asthma and Immunology. Because CMS calculates the antigen costs and administrative overhead based on preparing 1 cc, you may report only a concentrated dose or the highest concentration of the vaccine that the family physician (FP) plans on using as the therapeutically effective dose.
 
Let's compare these two definitions and how they impact billing. Consider how you would report 95165 for non-Medicare carriers in the following clinical example:
 
A physician prepares a 10-dose multidose vial for a patient and administers one injection to the patient containing one dose from the vial.
 
For the antigen preparation and provision, you should report 95165 x 10. Because CPT interprets a dose as the equivalent to the amount of serum drawn up in the injection, and the vial contains 10 doses, the antigen preparation and provision code should contain a 10 in the units box. In addition, assign 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) for the one injection.
 
Using the same clinical example, if the 10-dose multi-dose vial is 5 ccs, you should bill Medicare for 95165 x 5 and 95115. Because Medicare interprets a billable dose as the amount of maintenance concentrate contained [...]