Wiki 95117 / Allergy injections - documentation requirement

[MRC_CPCCRC]

Greetings all Our practice is considering adding administration of allergy immunotherapy injections to our list of services (CPT 95115/ 95117). The patients will bring the substance vials from their allergist. Other than the supporting Dx, what documentation MUST the Note include? It is a recurring & straightforward nurse visit with no assessment or eval component. Any assistance is GREATLY appreciated.

 

[rthomas@impcna.com]

Greetings all Our practice is considering adding administration of allergy immunotherapy injections to our list of services (CPT 95115/ 95117). The patients will bring the substance vials from their allergist. Other than the supporting Dx, what documentation MUST the Note include? It is a recurring & straightforward nurse visit with no assessment or eval component. Any assistance is GREATLY appreciated.

We only provide this service to our established patients.

Pt/caregiver instructed epipen must be present for allergy injection to be given. We ask that the patients stay in the office for 30 mins after injection(s). 95115/95117 is the only code billed if it is the only reason the patient is in the office unless they have a reaction. We require our nurses to document the info below. We do have a template created to make sure everything is captured.

Does the patient have an EpiPen present?
Exp date of EpiPen:
Vial color:
Exp date:
Amount administered:
Injection location & route:
Administered by:
Time injected:
Did the patient stay as instructed?:
If the patient stayed, time injection site checked for reaction.
Reaction?:

 

[MRC_CPCCRC]

We only provide this service to our established patients.

Pt/caregiver instructed epipen must be present for allergy injection to be given. We ask that the patients stay in the office for 30 mins after injection(s). 95115/95117 is the only code billed if it is the only reason the patient is in the office unless they have a reaction. We require our nurses to document the info below. We do have a template created to make sure everything is captured.

Does the patient have an EpiPen present?
Exp date of EpiPen:
Vial color:
Exp date:
Amount administered:
Injection location & route:
Administered by:
Time injected:
Did the patient stay as instructed?:
If the patient stayed, time injection site checked for reaction.
Reaction?:

I truly appreciate you taking the time to respond to my query, Ms. Thomas. This documentation outline is super helpful! I suppose the only thing we'd change is the epipen portion, if they come with antigen vials that have to be drawn. Last question, if I may: am I right in insisting to my clinical director that the Dx for which the patient is being given the allergy immunology injections is required, and it can not only be "Z51.6 - Encounter for desensitization to allergens"? THANK YOU AGAIN!!

 

[rthomas@impcna.com]

I truly appreciate you taking the time to respond to my query, Ms. Thomas. This documentation outline is super helpful! I suppose the only thing we'd change is the epipen portion, if they come with antigen vials that have to be drawn. Last question, if I may: am I right in insisting to my clinical director that the Dx for which the patient is being given the allergy immunology injections is required, and it can not only be "Z51.6 - Encounter for desensitization to allergens"? THANK YOU AGAIN!!

No problem, happy to help. Yes, you can use dx Z51.6 but it may depend on the insurance. When it comes to Medicaid and the Medicaid managed care plans, they want us to use T78.49XA for the first time the patient comes in to have it administered and T78.49XD for each administration after that.

 

[MRC_CPCCRC]

No problem, happy to help. Yes, you can use dx Z51.6 but it may depend on the insurance. When it comes to Medicaid and the Medicaid managed care plans, they want us to use T78.49XA for the first time the patient comes in to have it administered and T78.49XD for each administration after that.

You're a rockstar! Thanks again. Wishing you a wonderful Memorial Day weekend!!