Wiki ALLERGY BILLING SPECIALIST NEEDED!

[mcwhbo]

One of the doctors that I work for does allergy skin test (95004) & the allergy injections (95115 & 95117) & the mixing & prep of the allergy serum (95165). We are getting denials for 95165 requesting medical records & when we send in the mixing instructions and mixing receipt, we are told that they do not match up to the 20 units that we are trying to bill out. If you have any advice, I am quite literally begging for it.

 

[avidsky]

One of the doctors that I work for does allergy skin test (95004) & the allergy injections (95115 & 95117) & the mixing & prep of the allergy serum (95165). We are getting denials for 95165 requesting medical records & when we send in the mixing instructions and mixing receipt, we are told that they do not match up to the 20 units that we are trying to bill out. If you have any advice, I am quite literally begging for it.

I am trying to find clear 'official' documentation requirements as well.
While not 'official', I did find this on a website.

Payer Policy Considerations: Documentation and Unit Limits​

Beyond Medicare, private payers also have their own specific policies for CPT 95165. It is imperative for practices to regularly review and understand the guidelines of each insurer they work with. Common considerations include:

• Documentation Requirements: Many insurers require detailed documentation to support the medical necessity of allergen immunotherapy and the services billed under 95165. This often includes:
  • Identity of the prescribing physician.
  • Patient information and clinical indications for immunotherapy.
  • A brief description of the treatment plan and its formulation date.
  • Response to immunotherapy and the need for continued treatment at routine visits. While some payers might request compounding logs or specific lot numbers, professional organizations often deem these unnecessary and burdensome.
• Dose Limitations: Private payers may impose annual or per-period limits on the number of billable doses for CPT 95165. For instance, some policies might cap CPT 95165 at 150 units per patient per year, or even 250 units per rolling 12-month period across all providers. Practices must be vigilant in checking each payer’s specific unit limitations to avoid denials.
• Medical Necessity: All services, including the preparation of antigens, must be medically necessary and thoroughly documented. This includes clear rationale for the chosen allergens, concentrations, and dosing schedule.