Wiki IMMUNOTHERAPY- CPT 95165-76 Help!?

[danaguy71@yahoo.com]

I have a FL Medicaid provider who's specialty is Allergy & Immunology. He is performing allergy injections (CPT code 95117). As an example, one of his patients has been getting the injections for a couple of years according to medical records and claims history reviewed. The patient is coming in 1-3 times per month (usually twice a month) and the provider bills 95117, 1 unit for each injection. What I don't understand is that, when it is time for the preparation of the immunotherapy (CPT code 95165) they bill 95165, 25 units and bill the code again, 99165-76 (repeat service) for another 25 units. So, they are being paid twice for this.

I'm not questioning that the services are not needed, documentation indicates they are. I just don't understand why every time they bill for the prep, they bill twice, once with modifier 76 for repeat service. The documentation indicates that the patients HAVE to come into the office to get the injections so they can be monitored for reactions and such. I understand that it can take up to 3 years of repeated injections for therapy to be effective.

The patient in question was diagnosed with allergic rhinoconjuctivitis and had multiple positive skin test reactions to food. Therefore the provider recommended and started the immunotherapy. The records they sent for the DOS for the preparation do not address the billing issue I am concerned with (99165, 99165-76). The FL Medicaid policy doesn't appear to address this issue either. It just speaks to "medical necessity". Could this billing be so they have enough to cover the monthly injections assuming that the patients will come in for their scheduled therapy? Does this sound like a normal billing practice? If not, what do you suggest?
thank you!

 

[SharonCollachi]

Is he injecting 25 units two times per month (or planning on injecting two times per month)? If so, then the preparation sounds correct. Here is some Medicare info that may help:

If a patient’s doses are adjusted (e.g., due to reaction), and the antigen provided is actually more or fewer doses than originally anticipated, make no change in the number of doses billed. Report the number of doses actually anticipated at the time of the antigen preparation. These instructions apply to both venom and non-venom antigen codes. The physician should make no change in the number of doses for which he/she bills even if the patient’s doses are adjusted. The number of doses anticipated at the time of the antigen preparation is the number of doses that should be billed. If the patient actually receives more doses than originally planned (due to a decrease in the amount of antigen administered during treatment) or fewer doses (due to an increase in the amount of antigen administered), no change should be made in the billing.

Here is the link to the info.

And here is info from this website (AAPC).

 

[danaguy71@yahoo.com]

Thanks. That helps a little, but I am still confused. I think it's the number of units and what exactly that means for each code in relation to the units for the injections that follow that I don't understand. From what I can tell, he plans on injecting 2-3 times per month. According to the claims I am reviewing, it appears the patients usually come in 2-3 times per month after the prep code billing. It's usually about twice monthly. Here is another example:

There is a claim dated 11/08/2018 where the provider has billed 95165, 95165-76, both codes indicate 25 units. So he has actually billed 50 units. After that, the patient shows claims twice monthly for 95117 for the actual injection (1 unit always billed for this code). He doesn't bill 95165, 95165-76 again until 11/15/2019 (right at a year later). So I'm guessing that means the 50 units he originally billed is to cover for the injections for a year? If so, I'm assuming that if the patient decides to stop coming in for treatment halfway through the year, or even right after, it doesn't matter and the provider would still get paid because that was the plan?

thanks again

 

[SharonCollachi]

Extract Stability Rules - Immunotherapy treatment sets
1:10 –1:5000 –one year
1:50,000 and weaker –3-6 months
500 AU/ml and stronger –1 year, <500AU -3-6 months
1000 BAU/ml and stronger –one year
<1000 BAU –3-6 months

 

[danaguy71@yahoo.com]

Thanks again. I found that as well which is kind of like a foreign language to me LOL. I don't really understand that in relation to what that means for 25 units of 95165. However, I did find this:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

20.2 - Physician Expense for Allergy Treatment (Rev. 1, 10-01-03) B3-2005.2, B3-4145 Allergists commonly bill separately for the initial diagnostic workup and for the treatment (See §60.2). Where it is necessary to provide treatment over an extended period, the allergist may submit a single bill for all of the treatments, or may bill periodically. In either case the Form CMS-1500 claim shows the Healthcare Common Procedure Coding System (HCPCS) codes and from and through dates of service, or the Form CMS-1450 outpatient claim shows the HCPCS code and date of service (except for critical access hospital (CAH) claims).

So I take this to mean that billing for the preparation for the full year up front is acceptable.