Wiki 95165 Denials

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shain.mastroianni@allergyasthmaclinicltd.com

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Optum is denying 95165 stating that this code requires an injection code or modifier. Anyone else seeing this denial? If so, what are you doing to get it processed & paid. Thank you in advance
 
it looks like you need to add the administration

per EncoderPro (emphasis added by me):

These codes report the physician's preparation of an antigen for allergen immunotherapy and the provision of the antigen extract itself. These codes also include the providing physician's calculations for the concentration and volume to be used in the dosage based upon the patient's previous skin test results and personal history. These codes do not, however, include the administration of the allergen therapy. The number of doses must be specified and the vial(s) (series of vials from a treatment board or one multiple dose vial) from which the dose may be drawn is irrelevant. Report the code based on the type of preparation, i.e., the number of different venoms contained in a single administered injection of the extract. Report 95145 for a dose containing one single stinging insect venom, 95146 for an extract containing two single stinging insect venoms, 95147 for three, 95148 for four, and 95149 for five single stinging insect venoms in one dose extract. Code 95165 reports single or multiple antigens (not stinging insect), and 95170 is for a whole body extract of a biting insect or other arthropod.
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per CMS Billing and Coding Article: Allergy Immunotherapy:

To bill for 95165, the number of doses must be designated.
If a physician prepares the allergen and administers the injection on the same DOS, bill the appropriate injection code (CPT codes 95115 or 95117) AND the appropriate preparation (single dose) code (CPT codes 95145-95170). For billing, need to specify the number of doses in the days/units field
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and here is a cool article: CPT 95165 Coding Conundrums
 
Hopefully someone who codes Allergy, will chime in, but per the LCD/coding article, it sounds like it cannot be billed separately.
wish I could be more help.

per the CMS billing and coding article:

Separate coding for injection only codes (i.e., codes 95115 and 95117) and/or the codes representing antigens and their preparation (i.e., codes 95144 through 95170) must be used.
If both services are provided both codes are billed.
This includes allergists who provide both services through the use of treatment boards.
 
lgardner said:
Hopefully someone who codes Allergy, will chime in, but per the LCD/coding article, it sounds like it cannot be billed separately.
wish I could be more help.

per the CMS billing and coding article:

Separate coding for injection only codes (i.e., codes 95115 and 95117) and/or the codes representing antigens and their preparation (i.e., codes 95144 through 95170) must be used.
If both services are provided both codes are billed.
This includes allergists who provide both services through the use of treatment boards.
Click to expand...
No I appreciate you!!!! Thank you so much! Yes, anyone with Allergy coding knowledge, please help me lol
 
I work for an allergy office and we bill 95165 all the time and have not had to bill an injection code or add a modifier to bill a 95165
 
I agree I coded and billed 95165 x # of doses for five years with no issues. The mixing was never done on the same date as the injections, but I looked for a CCI edit on Optum 360 and there is none listed. Now we have lost our mixer and the office is contracting with an outside pharmacy to get the serum, who does not bill insurance, they bill us. So now I have to figure out how to bill for the serum and the injections when we are not making them but need to be paid for acquiring them. Any suggestions?
 
tswitzer said:
I agree I coded and billed 95165 x # of doses for five years with no issues. The mixing was never done on the same date as the injections, but I looked for a CCI edit on Optum 360 and there is none listed. Now we have lost our mixer and the office is contracting with an outside pharmacy to get the serum, who does not bill insurance, they bill us. So now I have to figure out how to bill for the serum and the injections when we are not making them but need to be paid for acquiring them. Any suggestions?
Click to expand...
I have the same issue, have you come up with a solution?

Also, do you have any guidance on what has to be documented to bill for 94165 or 95165?
Do you bill the serum mixing once and then bill only injections until another batch is needed or do you bill the mixing each time the injection is given?
Not finding very clear info about whether the serum info has to be documented each time it is billed or only at the start of treatment and anytime the serum is modified.
 
The vial billing 95165 is by insurance company billing guidelines. Who is Optum reviewing for, they aren't an insurance company. Every insurance company we bill to with the exception of Wellmark BC/BS wants the vial billed when it is made. Wellmark BC/BS wants the vial billed when the first injection and vial safety test are done out of the vial. Which to me is fraudulent because they have you change the DOS of the vial to the DOS of the injection so they all go together.
 
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