Pulmonology Coding Alert

When to pick 95115 over 95120

If you want to code your pulmonologist's immunotherapy treatments with confidence, you'll need to know when and how to report antigen injection and preparation services. Coding experts offer three tips to maximize your immunotherapy reimbursement.

When the physician provides immunotherapy, you have several codes to choose from, and a few to avoid.

Codes 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) and 95117 (... two or more injections) represent injection services. Report one code per session, depending on the number of injections the physician gave.

When your pulmonologist supervises and provides antigens, use 95144 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single dose vial[s] [specify number of vials]) or 95165 (... single or multiple antigens [specify number of doses]).

Remember not to report codes 95120-95134 (Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract ...) to Medicare, because these codes represent complete services that include both the injection and preparation. But Medicare wants practices to report each physician service, coding experts say.

To report the physician's injection and supervision for a single injection, use 95115 and 95165. For multiple injections, assign 95117 and 95165. In both cases, identify the number of doses, coding experts say.

You should report 95144 only when the physician provides the antigen for another physician to inject. Most insurance companies don't reimburse 95144, and physicians avoid using 95144 because it's too expensive, says Karen Jernigan, CPC, CMIS, office manager at the Asthma, Allergy, and Immunology Clinic, James Island, S.C. For this reason, Medicare pays 95144 claims at the 95165 rates, coding experts say.

Once you've learned how to use immunotherapy codes, you must support them with the appropriate ICD-9 codes. Knowing how to assign diagnosis codes becomes even more important now that the HHS Office of Inspector General targets immunotherapy services in its 2004 Work Plan. The OIG states that most immunotherapy claims lack sufficient medical documentation.

Suggest to the pulmonologist that he or she make clear in the patient's documentation that the patient has a year-round allergy, not just an occasional runny nose, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

For example, the pulmonologist treats a patient for allergic rhinitis (477.x) with two immunotherapy injections. You should report 95117 and 95165 for the injections. To prove medical necessity, link 477.x as the primary condition to both 95117 and 95165.

Your physician doesn't have to document the reason for immunotherapy every time he or she bills for 95165. But the physician should note in the chart that initial allergy testing indicated that the patient requires immunotherapy treatments, Callaway says.

3. Assign Codes Based on Payer-Defined Dose

Make sure you know the difference between a clinical dose and a billable dose before you send out your next claim for 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]). CPT defines a clinical dose as "the amount of antigen(s) administered in a single injection from a multiple-dose vial," Callaway says. "On the other hand, Medicare defines a billable dose, not a clinical dose, as 1 cc."

Although a physician may administer any antigen amount 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 in Palatine, Ill. Because CMS calculates the antigen costs and administrative overhead based on preparing 1 cc, you may report only a concentrated dose or the highest vaccine concentration that the pulmonologist determines is the therapeutically effective dose.

So how do the different dose interpretations impact 95165 billing? Review the following example:

The pulmonologist prepares a 10-dose 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 for private payers.

Because CPT interprets a dose as equivalent to the amount of serum the physician draws 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 single injection.

Using the same example above, if the 10-dose vial amounts to 5 ccs, you should bill Medicare for 95165 x 5 and 95115. Because Medicare interprets a billable dose as the amount of maintenance concentrate in the vial, you should report one unit per cc or five units of 95165. "You may not bill for dilutions of the maintenance concentrate," Atwater says.

For non-Medicare carriers, the clinical dose definition applies, coding experts say. Therefore, if you incorrectly assume that all payers follow Medicare's definition of 95165, you will forfeit the reimbursement for the clinical dose. Suppose you bill the above example to a private payer that follows the drawn-up definition using Medicare's cc formula. The error will cost your practice $9.93 per unit (95165 contains 0.27 nonfacility relative value units based on the Medicare Physician Fee Schedule). That means you will lose a total of $49.65 for the five additional units, assuming that the commercial plan's conversion factor is the same as Medicare's ($36.79). Most private insurers, however, pay more than Medicare, so the error could cost you more than $49.65.