Wiki Allergy Billing Question for code 95165

Create Wiki Sort by votes
M

MaryLynn

New
Messages
2
Location
Palatka, FL
Best answers
0
I need some assistance from an allergy biller and coder that is very familiar with the billing of code 95165. I just recently had some allergy testing performed on one date of service in my doctor's office. My doctor's office has billed my insurance company for code 95165 for seven consecutive days where they never even saw me, I was seen on the one day and billed and then after that they billed code 9516 for seven different days that I wasn't actually seen at all. They are telling me that this is how they bill for the allergy mixing and are able to bill this way even though they didn't actually see me on those days. Are they really able to bill this way? Is this ethical? I am CPC and have been doing billing and coding for over ten years for PCP's and specialists and now at an ASC. I have never heard of being able to bill a patient for a code on a date of service without ever actually seeing them. I really need some help on this. I don't know if this is normal and ethical or if this is some type of fraudulent billing that needs to be reported. Thank you in advance, I really need some assistance in this matter.
 
0
I code for a an ENT clinic and when they are mixing the allergy serum, that is the day we bill/charge the patient. You are being billed for the serum not a visit. Depending on what type of serum, sublingual or injection, if the patient would get a charge for the day they receive the serum. Sublinguals do not get charged because it is self administered and just supervised by the nurse. The injections do get a charge on the day they receive the injection. Hope this helps you! If someone knows something different I'd like to know also!!
 
0
EmilyCarl said:
I code for a an ENT clinic and when they are mixing the allergy serum, that is the day we bill/charge the patient. You are being billed for the serum not a visit. Depending on what type of serum, sublingual or injection, if the patient would get a charge for the day they receive the serum. Sublinguals do not get charged because it is self administered and just supervised by the nurse. The injections do get a charge on the day they receive the injection. Hope this helps you! If someone knows something different I'd like to know also!!
Click to expand...
So, just so I am understanding this correctly, they can bill for the mixing of serums code (95165), seven different times, on seven different dates, even though they never saw me or injected me with those serums? How is there any way to know if mixing (95165) was actually done on those days. One of the days is even a Saturday. Do you all bill this code out like this for the mixing of serums as well even though you don't see the patients? It's all just so foreign to me and it has resulted in $1500 of medical bills for me, and I am just blown away by this. Thanks again, just wanting to make sure that this is accurate billing and would like to know how they can prove to me that these mixings took place on those days and that many times. I appreciate it.
 
0
MaryLynn said:
So, just so I am understanding this correctly, they can bill for the mixing of serums code (95165), seven different times, on seven different dates, even though they never saw me or injected me with those serums? How is there any way to know if mixing (95165) was actually done on those days. One of the days is even a Saturday. Do you all bill this code out like this for the mixing of serums as well even though you don't see the patients? It's all just so foreign to me and it has resulted in $1500 of medical bills for me, and I am just blown away by this. Thanks again, just wanting to make sure that this is accurate billing and would like to know how they can prove to me that these mixings took place on those days and that many times. I appreciate it.
Click to expand...
I have billed these as well and the way your provider is billing it is based on what your insurance is dictating as a daily quantity limit. Medicare and UHC are notorious for having quantity limits on 95165. What the provider is mixing is what is required to treat you and if the payer restricts the provider to only billing a certain number of units per day then the provider is simply playing the game the payer created in order to get compensated for all of the work done. I would venture to guess it was also intentionally done by payers hoping providers/billers would simply bill the units done on the first day and stop and therefore dramatically underbill, letting the payers off the hook very cheap. I would suggest two things- first, review your EOB to see if your balance is due to deductible/coinsurance or if it is "not a covered service." If it is not a covered service, then you need to consider alternative treatment if it is a financial hardship in my opinion. Second, call your insurance and ask them to explain it to you. You/your employer are paying them a hefty premium each month to serve you, let them earn some of that and explain to you that they do not view this as fraud which I suspect is supported by your EOB's probably showing the charges as "allowed" vs. "denied" or "not covered" which is a good clue they are OK with what your provider is doing. Remember, if there is any possibility of the payer getting out of paying (or allowing) a claim they will certainly take advantage of it.
Hunter Smith, CPC
 
You must log in or register to reply here.
Top