Pulmonology Coding Alert

Correct code reporting for allergy immunotherapy hinges on understanding that physicians are to bill only for the component codes, i.e., the injection-only codes (95115 and 95117) and/or the codes representing antigens and their preparation (codes 95144-95170). Physicians providing both services should bill for both.

The CPT defines immunotherapy (desensitization, hyposensitization) as the parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage which is maintained as maintenance therapy. Understanding the differences between the following codes is critical to obtaining appropriate reimbursement for these codes:

95115-95117 professional services for allergen immunotherapy not including provision of allergenic extracts; single injection; and two or more injections,
respectively

95144 professional services for the supervision and provision of antigens for allergen immunotherapy, single or multiple antigens, single-dose vials [specify number of vials]

Editors note:Use 95144 instead of 95135 or 95140, which have been deleted in CPT 2000.

The office visit is a separate procedure, says Deanna Furman, president and CEO of MediPro Corporation, a physician billing service in North Little Rock, Ark. The patient comes in initially for the office visit [99212-99215] and scratch test. Then the serum is created [95144]. After that the patient comes back to the allergist or takes the serum to their general practitioner and keeps getting the shots how ever often they need to get them [95115 or 95117).

Know When to Use Modifier -25 and Bill for an Office Visit

The CPT reads that codes 95115 to 95199 include the professional services necessary for allergen immunotherapy. Office visit codes may be used in addition to allergen immunotherapy if other identifiable services are provided at that time. What you need to remember, says Furman, is that if youre going to bill an office visit, you have to use modifier -25 and show a separate diagnosis.

CPT modifier -25, according to CPT 2000, is a significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service. The modifier is attached to the E/M code and not to the service code.

A patient cant be coming in for the same thing shes getting a shot for, Furman continues. The patient has to have some other flare-up to bill an office visit. This becomes tricky when youre trying to do [the injections] the same day as the office visit. Make sure you use your modifier and separate diagnosis.

According to the American Medical Association (AMA), The physician may need to indicate that on a day a procedure or service identified by a CPT code was performed, the patients condition required a significant, separately identifiable E/M service above and beyond the other service provided... The key words here are a significant and separately identifiable service. So if a patient comes in for an injection and the physician asks her only about reactions to previous injections, the physician could not use modifier -25 or bill for an E/M service because these questions are part of the injection codes. But, if the physician obtained a general medical updated history relative to symptoms and drug therapy, he or she should bill for both the injection (95115 or 95117) and the appropriate E/M service (99212-99215) using modifier -25.

Remember that all services are subject to review for medical necessity. Therefore, if a patient with seasonal allergic rhinitis had his/her medical history updated every visit an injection was received, the reviewer probably would find that the patient was receiving services in excess of his/her needs, and most of the E/M visits would be prohibited. But the patient with seasonal allergic rhinitis who had an E/M visit every three or six months while receiving new allergy extracts, probably would not be receiving excessive services and payments should not be denied.

How to Bill if an Outside Entity Creates the Antigen

Some allergists have the antigen created elsewhere, such as a pharmaceutical company, according to Mary Jean Sage, CMA-AC, principal consultant with Sage Associates in Arroyo Grande, Calif. In these instances, the antigen preparation is considered part of the patients prescription program or medication benefit, explains Sage. This is especially true with managed care plans.

When you report 95165 (professional services for the supervision and provision of antigens for allergen immunotherapy; single or multiple antigens [specify number of doses]) occasionally that will go to a different carrier. Blue Cross is notorious for that, she says, Find out which carrier the patients pharmacy program is with. The antigen is considered part of the prescription program, or medication benefit. Sage adds that carriers will consider the antigen creation a preauthorized procedure. This means that you should know your time limitations for dosage administrations.

Sage also reminds coders that 95165 should be reported when you are using both 95115 (or 95117) and 95144.

Code 95144 (single dose vials of antigen) should be billed only if the physician who creates the antigen is creating it to be injected by some other entity. An example of this is when the primary care physician gives the patient an injection using an antigen provided by an allergist. Single dose vials should be used only as a means of insuring proper dosage amounts for injections because they are more costly than multiple dose vials (code 95165). Allergists who prepare antigens are assumed to be able to administer the appropriate dosage from the less costly multiple-dose vials.

Codes 95145 to 95149 are components of immunotherapy-antigen preparation. If the allergist provides both components of the service, he or she would use one of the injection codes (95115 or 95117) and one of the preparation codes (95145-95149).

When billing codes 95144-95170, physicians should specify the number of doses provided in the units field. Code 95165 represents multiple-dose vials. A dose, in 95165, is the total amount of antigen to be administered to a patient during one treatment session. Physicians must specify the number of doses provided in the entire session.

If there are limitations that only allow minimal dosages, you want to make sure you have the flexibility to carve out or negotiate the existing contract to reflect any changes, suggests Sage. Because each patient is different, they all dont progress at the same rate.

Document to Support Medical Necessity

Submit documentation, such as ICD-9 codes, to support the medical necessity of each item on the claim. Claims submitted without such evidence will be denied as being not medically necessary. Documentation in the progress notes must reflect medical necessity and be available on request.

Editors note: Antigens administered sublingually (i.e., by placing drops under the patients tongue) are not reimbursable. Antigens are covered only if they are injected.

In addition to the allergist administering injections, a licensed physician assistant or nurse (under the supervision of the physician) may administer injections, or the patient may self-administer.