Navigating the complexities of medical billing, especially for specialized treatments like allergy injections (immunotherapy), can be challenging. Accurate coding is crucial for healthcare providers to ensure proper reimbursement and compliance, particularly within the Medicare system. This guide aims to clarify the coding and billing guidelines for allergy injections, drawing from official Medicare resources to provide a comprehensive understanding for healthcare professionals. Understanding these specific codes is essential for allergists, primary care physicians, and billing staff involved in administering and billing for allergy immunotherapy services.
Understanding Allergy Injection Coding Information
When it comes to coding for allergy injections, it’s important to distinguish between codes for the injection service itself and codes for the preparation of the allergenic extracts. Medicare has specific guidelines and code sets that must be followed to ensure accurate billing and avoid claim denials.
Key Billing Guidelines for Allergy Injections:
Medicare’s National Correct Coding Initiative (NCCI) edits are vital to consider. According to the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 11, Evaluation and Management (E&M) codes should only be reported alongside allergy immunotherapy codes if a significant, separately identifiable service is performed. This means that routine services that are inherently part of the immunotherapy process, such as obtaining informed consent, should not be billed separately as E&M services. If a distinct E&M service is indeed provided, it is necessary to append modifier 25 to the E&M code to indicate that it is a separately identifiable service.
Non-Covered Allergy Services:
It is important to note that Medicare does not cover certain types of allergy testing and treatments. Specifically, as of October 31, 1988, sublingual, intracutaneous, and subcutaneous provocative and neutralization testing, as well as neutralization therapy for food allergies, are excluded from Medicare coverage. This exclusion is based on the determination that available evidence does not demonstrate the effectiveness of these methods, as outlined in CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2 Section 110.11.
Medicare Physician Fee Schedule and Allergy Immunotherapy:
Since January 1, 1995, all antigen/allergy immunotherapy services have been paid under the Medicare physician fee schedule. This shift, as detailed in CMS Publication 100-04, Medicare Claim Processing Manual, Chapter 12, Section 200, standardized the payment process for these services.
Invalid CPT Codes for Medicare:
CPT codes 95120 through 95134 are not valid for Medicare billing. These codes are considered “complete service” codes, meaning they bundle both the injection service and the antigen preparation. Medicare requires separate coding for these components.
Separating Injection and Antigen Preparation Codes:
For services provided on or after January 1, 1995, billing must utilize separate codes for the injection itself (codes 95115 and 95117) and for the antigens and their preparation (codes 95144 through 95170). Crucially, if both the injection and antigen preparation services are provided by the same physician or practice, both sets of codes must be billed to accurately reflect the services rendered. This is particularly relevant for allergists who manage both aspects of allergy immunotherapy, often utilizing treatment boards within their practice.
Billing for Injection and Antigen Codes Together:
When a physician bills for both an injection code (95115 or 95117) and an antigen preparation code (95165 or 95144), Medicare Administrative Contractors (MACs) will process the claim by paying the appropriate injection code and the rate associated with code 95165 (multiple dose vials). Specifically, if code 95144 (single dose vials) is billed alongside an injection code, MACs will adjust the payment to align with the 95165 rate. This policy reflects the understanding that while single-dose vials (95144) are intended for situations where the antigen is prepared by one entity and administered by another, allergists who prepare their own antigens are expected to use cost-effective multiple-dose vials (95165) for their practice. Therefore, even if single-dose vials are used or billed by allergists providing both services, reimbursement will be based on the multiple-dose vial rate.
Dose Specification for Antigen Codes:
The fee schedule amounts for antigen codes (95144 through 95170) are based on a single dose. When billing these codes, it is mandatory to specify the number of doses provided in the claim. Medicare will then calculate payment by multiplying the fee schedule amount by the number of doses indicated in the units field of the claim.
Adjustments in Doses and Billing:
In the course of allergy immunotherapy, patient doses may need adjustment due to reactions or changes in treatment plans. It is important to understand that billing should not be altered based on these adjustments. The number of doses to be billed is determined by the number of doses prospectively planned at the time of antigen preparation. This policy, consistent with guidance from the American Medical Association’s CPT Assistant, means that whether a patient ultimately receives more or fewer doses than initially anticipated from a vial due to dose adjustments, the billed number of doses remains unchanged. Medicare will not provide additional payment for increased doses administered from the original vial, nor will they seek recoupment if fewer doses are administered. This rule applies to both venom and non-venom antigen codes.
Venom Dose Coding and Catch-Up Billing:
Venom doses in allergy immunotherapy have specific coding considerations. Venom antigens are prepared in separate vials and are not mixed, except for the three vespid mix. Codes 95146 through 95149 are used for multiple venom doses, with each code representing a specific number of venoms (e.g., 95146 for two venoms, 95148 for four venoms). To use these codes, some amount of each venom included in the code must be administered.
Dosage adjustments can lead to asynchronous administration of venoms. Medicare policy prioritizes payment at the highest venom level possible for patients undergoing multi-venom therapy (two, three, four, or five venoms). Therefore, billing should aim to use the highest appropriate venom code (95146, 95147, 95148, or 95149) to the greatest extent possible.
In situations where a “catch-up” dose of a specific venom is needed due to dosage adjustments, physicians should prepare and bill only for the replacement venom dose using the appropriate single-venom code (e.g., 95145 for a single venom). This allows for synchronization back to the higher multi-venom codes as quickly as possible, optimizing billing under Medicare guidelines.
Code 95165 and Non-Venom Antigen Doses:
Code 95165 applies to the preparation of vials containing non-venom antigens. Similar to venoms, certain non-venom antigens cannot be mixed and must be prepared in separate vials. The practice expense component for mixing a multidose vial of antigens is calculated based on a standard 10cc vial, with 1cc aliquots considered a typical dose volume.
While physicians are not mandated to use 1cc aliquots, the practice expense reimbursement for code 95165 is capped at 10 doses per vial. Billing for more than 10 doses from a single multidose vial is not permissible under Medicare, even if more doses are extracted. This limit ensures that Medicare does not overpay the practice expense component associated with vial preparation. It’s important to note that code 95165 covers antigen preparation only and does not include the injection itself, which is billed separately.
For multidose vials containing less than 10cc, billing should be proportional to the actual volume. Physicians should bill for the number of 1cc aliquots that can be removed from the vial, up to a maximum of 10 doses per vial.
Examples of 95165 Dose Billing:
To illustrate the application of code 95165 dose billing, consider these examples:
- If a 10cc multidose vial is filled to 6cc with antigen, bill for 6 doses.
- If a 5cc multidose vial is completely filled, bill for 5 doses.
- If a physician extracts 20 doses of ½ cc aliquots from a 10cc vial, bill for a maximum of 10 doses.
- For two 10cc multidose vials prepared, a maximum of 20 doses can be billed in total, regardless of aliquot size.
- If a 20cc multidose vial is prepared, bill for 20 doses, even if only 10 doses are extracted as 2cc aliquots.
- For a 5cc multidose vial, bill for 5 doses, even if ten ½ cc aliquots are extracted.
These examples clarify that the billing for code 95165 is based on the potential 1cc doses within a vial, up to a maximum of 10 doses per vial, reflecting the practice expense associated with vial preparation rather than the exact number of administered doses.
Allergy Shots and Evaluation and Management (E/M) Services on the Same Day:
Medicare guidelines address the billing of E/M services on the same day as allergy injections (CPT codes 95115-95117). Generally, E/M services should not be billed on the same day as allergy injection services unless the E/M visit represents a significant, separately identifiable service. This principle aligns with CPT guidelines for allergen immunotherapy codes.
Since January 1, 1995, global surgery policies have been applied to allergen immunotherapy codes, including injection codes 95115 and 95117. The global surgery indicator for these codes was changed to “000,” indicating that the global surgery concept applies but with a zero-day postoperative period.
To bill for an E/M service on the same day as allergen immunotherapy, modifier 25 must be appended to the E/M code. This modifier signifies that the patient’s condition required a significant, separately identifiable E/M service that was distinct from the allergy injection service. Without modifier 25, claims for same-day E/M services and allergy injections are likely to be denied.
E/M services are permissible in addition to codes 95115 or 95117 only when separately identifiable services are provided concurrently.
CPT Codes 95115 and 95117: Injection Administration Only:
CPT codes 95115 (single injection) and 95117 (multiple injections) specifically cover the professional administration of the allergenic extract. These codes are used when the allergenic extract is not included in the code descriptor, meaning the antigen preparation is billed separately or provided by another entity. These codes do not encompass the provision or preparation of the extract itself.
For instance, if an allergist provides the extract and a separate physician (like a family practitioner) administers the injection, code 95115 or 95117 would be used by the administering physician. It is critical to note that codes 95115 and 95117 should not be billed if the patient self-administers the antigen. Only one of these codes (95115 or 95117) should be billed per date of service, with a unit quantity of 1. Billing both 95115 and 95117 on the same date of service is not allowed.
Using Codes 95115/95117 with Antigen Preparation Codes (95145-95170):
When reporting both the injection administration and the antigen/antigen preparation service (i.e., a complete allergy immunotherapy service), it is necessary to use CPT codes 95115 or 95117 in conjunction with the appropriate CPT code from the range 95145-95170. This guideline also applies to allergists who provide both services through treatment boards within their practice.
CPT Code 95165: Antigen Preparation (Single or Multiple Antigens):
CPT code 95165 covers the preparation of allergenic extracts, whether involving single or multiple antigens. However, it does not include the administration of the injection. Therefore, when a physician prepares the allergenic extract(s) and also administers the extract(s) via single or multiple injections, code 95165 should be reported in addition to either 95115 or 95117. When billing for 95165, the number of doses prepared must be specified.
Billing for Preparation and Injection on the Same Day:
If a physician both prepares the allergen and administers the injection on the same date of service, the billing must include the appropriate injection code (95115 or 95117) and the appropriate preparation code (from the single-dose codes 95145-95170). The number of doses must be indicated in the days/units field for billing accuracy.
CPT Code 95170: Fire Ant Extract:
CPT code 95170 is exclusively for billing fire ant extract. Its use is limited to this specific type of allergenic extract.
Single Dose Vials vs. Multi-Dose Vials:
A single-dose vial contains a single dose of antigen intended for administration in one injection. For allergy immunotherapy billing, a “dose” is defined as the amount of antigen(s) administered in a single injection from a multiple-dose vial. For multi-dose vials containing less than 10cc, billing is based on the number of 1cc aliquots that can be removed, up to a maximum of 10 doses per multi-dose vial. Billing for the preparation of more than one multi-dose vial may be justified if medically necessary, provided that the medical necessity is documented in the patient’s medical record.
Modifier EJ for Maintenance Allergy Immunotherapy:
Claims for maintenance allergy immunotherapy treatments require the use of the EJ modifier. This modifier helps to identify claims related to the maintenance phase of immunotherapy, which may have different coverage or processing rules.
Coding Guidelines Summary
Allergen immunotherapy coding is broadly divided into codes for the injection administration and codes for the antigen preparation. It’s critical to consult the NCCI edits in the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 11, Section K, for comprehensive coding guidelines.
Allergy Testing and Immunotherapy on the Same Day:
Generally, allergy testing and allergy immunotherapy are not performed on the same day in standard medical practice. Allergy testing is typically conducted prior to initiating immunotherapy to identify the specific allergens. Billing codes for allergy testing and immunotherapy on the same date of service is generally not appropriate unless allergy immunotherapy is administered and testing for additional allergens is also performed on the same day. Importantly, allergy testing codes should not be reported for allergen potency (safety) testing conducted prior to immunotherapy administration, as this is considered an inherent component of immunotherapy. Furthermore, allergy testing is an integral part of rapid desensitization kits (CPT code 95180) and should not be billed separately when using these kits.
Scope of Codes 95115-95199:
CPT codes 95115-95199 encompass the professional services necessary for allergen immunotherapy. Office visit codes (E/M codes with modifier 25 when appropriate) may be billed in addition to allergen immunotherapy codes if separately identifiable services are provided during the same encounter.
CCI Edits and Code Combinations:
The HCPCS/CPT codes for allergy immunotherapy are subject to Correct Coding Initiative (CCI) edits. Medicare’s CCI edits take precedence over general policy guidelines. Providers must refer to the CCI for correct coding guidelines and specific code combination restrictions before billing Medicare.
Invalid CPT Codes 95120-95134 for Medicare (Reiteration):
As previously mentioned, CPT codes 95120 through 95134 are not valid for Medicare billing. These codes represent bundled services that are not recognized under Medicare’s unbundling requirements for injection and antigen preparation.
CPT Codes 95144-95170: Antigen Provision Only:
CPT procedure codes 95144-95170 are used to report the antigen/antigen preparation service (professional component) when this is the only service rendered by the physician. The specific code within this range depends on the type of antigen provided.
- CPT Code 95144: Used for antigens other than stinging insect venom, specifically for single-dose vials. This code should only be used when the allergist prepares the extract and provides it to be injected by another entity. If mistakenly billed with an injection code (95115 or 95117) when both services are provided, payment will be adjusted to the 95165 rate.
- CPT Code 95165: Used for multiple-dose vials of non-venom antigens. A “dose” for code 95165 is defined as a 1cc aliquot from a single multidose vial. Billing should reflect the number of 1cc doses prepared, with a maximum of 10 doses billable per vial under Medicare. Diluted preparations exceeding the 10-dose limit per vial should not be billed to Medicare.
CPT Codes 95145-95149 and 95170: Stinging Insect Venoms:
CPT codes 95145-95149 and 95170 are designated for stinging insect venoms. Venom doses are prepared separately (except for the three vespid mix). The appropriate code within this range depends on the number of venoms provided. If a multi-venom code is used, some amount of each venom must be administered. Using a lower venom code should only occur for “catching up” venom synchronization after dosage adjustments.
Antigen codes in the range 95144-95170 are considered single-dose codes, and the number of doses provided must be specified when reporting these codes.
CPT Code 95180: Rapid Desensitization:
CPT procedure code 95180 (rapid desensitization) is used when desensitization to a drug is medically necessary. This procedure requires frequent monitoring and skin testing. The number of hours involved in the desensitization process must be reported in the unit field when billing code 95180.
Place of Service Considerations
The place of service also affects the payment for certain allergy injection codes:
- CPT Codes 95115 and 95117: Payable only in an office setting.
- CPT Codes 95144 and 95145-95170: Payable in office and outpatient hospital (both on-campus and off-campus) settings. These codes are also payable in a skilled nursing facility if the physician is present.
- CPT Code 95180: Payable in office, outpatient hospital, inpatient hospital, and emergency room settings.
Antigens: Reasonable Supply Guidelines
Medicare allows payment for a reasonable supply of antigens prepared for a specific patient, even if they are not administered by the same physician who prepared them, under these conditions:
- The antigens are prepared by a physician (MD or DO).
- The physician has examined the patient, established a treatment plan, and determined a dosage regimen.
A reasonable supply of antigens is defined as no more than a 12-month supply prepared at any one time. This limitation ensures antigen potency and effectiveness over the treatment period.
Conclusion:
Accurate billing and coding for allergy injections are paramount for healthcare providers. Adhering to Medicare guidelines, understanding the nuances of injection codes, antigen preparation codes, and place of service rules, and correctly applying modifiers like EJ and 25 are essential for compliant and successful reimbursement. This guide provides a detailed overview to assist providers in navigating these complexities and ensuring accurate financial practices for allergy immunotherapy services.
