95125 Billing
According to CMS coding guidelines:
•When a physician prepares the allergenic extract(s) (same or different antigens), and administers the extract(s) using single or multiple injections, code 95165 should be reported in addition to either 95115 or 95117. If both services are provided, both codes are billed.
•CPT codes 95120 – 95134 represent complete services (i.e. services that include the injection services as well as the antigen and its preparation. These codes are not valid for Medicare purposes, therefore, no reimbursement will be provided.
Allergen Immunotherapy
Allergen immunotherapy by intradermal or subcutaneous injection meets the definition of medical necessity when administered for the treatment of patients demonstrating hypersensitivity to specific antigens that cannot be managed by medications or avoidance.
Allergen immunotherapy services may include one or more of the following:
•Patient evaluation related to the supply or administration of the allergenic extract (allergen vaccine)
•Supplies (needles, syringes, diluents)
•Monitoring the physical status of the patient during administration of the extract (allergen vaccine.)
Professional services for allergen immunotherapy may include A and B, A or B, or C below:
1.Administration of the allergenic extract(s) (allergen vaccine) only, not including the provision (supply) of the extract(s) (allergen vaccine) (95115, 95117)
2.Supervision, preparation and provision (supply) of extract(s) (allergen vaccine) only (95144, 95145 – 95149, 95165, 95170)
3.Administration and provision (supply) of extract(s) (allergen vaccine) (95120, 95125, 95130 – 95134.)
Based on the guidelines of the American Academy of Allergy, Asthma, and Immunology (AAAAI), extracts (vaccines) with high proteolytic enzyme activities (e.g., fungi, dust mites, cockroach, and insect venoms) are separated from those without proteolytic enzyme activities. Therefore, patients should typically require only two (2) vials of allergen extract(s). Any excess of three (3) multi-dose vials would be subject to review by the Medical Director of the payer.
Allergy injections for Family Practice Management
Q:
What code should our hospital-based clinic submit for an allergy injection when we provide the antigen? What about when an outpatient pharmacy provides the antigen to us?
A
When your clinic provides and administers the allergenic extract (i.e., antigen), you should submit 95120 or 95125 for “professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract,� depending on the number of injections given. These codes describe the entire service of preparing, providing and administering the antigen at a single patient encounter. If an outpatient pharmacy provides the antigen to the patient, who brings it to your clinic for administration, you should submit 95115 or 95117 for “professional services for allergen immunotherapy not including provision of allergenic extracts,� again depending on the number of injections given. These codes reflect the administration (i.e., injection) of the antigen; they do not include the provision or preparation of it.
Note that Medicare requires you to bill only the component codes; it does not accept the complete allergy codes 95120 and 95125. If you provide the complete service (i.e., preparation and administration of the antigen) to a Medicare patient, you should submit the appropriate codes that represent the antigens and their preparation (95144–95170) in addition to the administration code (95115 or 95117).
Kent Moore is the AAFP's manager for health care financing and delivery systems and is a contributing editor to Family Practice Management. These questions and answers were reviewed by members of the FPM Coding & Documentation Review Panel, which includes: Robert H. Bosl, MD, FAAFP; Marie Felger, CPC; Thomas A. Felger, MD, DABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic; Lynn Handy, CPC, LPN; Emily Hill, PA-C; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC.
Conflicts of interest: none reported.
Editor's note: While this department represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will accept the coding and documentation recommended. Because CPT and ICD-9 codes change annually, you should refer to the current CPT and ICD-9 manuals and the “Documentation Guidelines for Evaluation and Management Services� for the most detailed and up-to-date information.
