Wiki Allergy - to prepare antigens for allergy immunotherapy 95165

[clbcarey@comcast.net]

Received a denial from Medicare for 95165, because patient was inpatient on the same date. We had explained that this was just the preparation of the antigen, but they stated it did not matter and they want their money back.

How can we get this claim paid without having to worry about a refund request?
Any help would be appreciated.

 

[b.cobuzzi]

What I understand is you mixed the serum while the patient was an inpatient, not even necessarily knowing the patient was inpatient at the time.

The allergy process is to do testing and bill the testing on the DOS that the testing occurs.
Then the supervision and preparation of the serum takes place when the patient is not present and you billed when you performed the service (and the patient incidentally happened to be in the hospital)
The immunotherapy is billed the DOS when the shots are administered.

Practices will often use the DOS for the first immunotherapy shot for billing 95165 since the patient is present at that time, even though the patient does not need to be present. But as you see you do not want to take the chance that the patient might be a different status, such as inpatient.

I would appeal the refund again, sending in the documentation and ask if the date of service can be changed to the date the patient first received their first immunotherapy shot. Send in both the mixing documentation and the immunotherapy documentation with the appeal. Note, since you were denied the appeal at the carrier level, you need to appeal to reconsideration, to the QIC.

Make sure you are not billing for more than the amount of maintenance doses. Medicare Part B does not pay for diluting units beyond the maintenance dose.