95165 Professional Services Supervision Provisions Antig
95115 – Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection
95117 – Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections
ALLERGY TESTING AND ALLERGEN IMMUNOTHERAPY
In billing for allergy testing and allergen immunotherapy, providers are to use the most appropriate and inclusive Procedure code that describes the services provided. Unless otherwise listed, Louisiana Medicaid uses the definitions and criteria found in the Current Procedural Terminology Manual (Procedure ).
Definitions
Allergy testing describes the performance and evaluation of selective cutaneous and mucous membrane tests in correlation with the history, physical examination, and other observations of the recipient. The number of tests performed should be judicious and dependent upon the history, physical findings, and clinical judgment of the provider. All patients should not necessarily receive the same tests or the same number of tests.
Immunotherapy is the parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage which is maintained as maintenance therapy. The method of administration and the dosage administered should be included in the recipient’s record. Indications for immunotherapy are determined by appropriate diagnostic procedures and clinical judgment. The procedure codes used for allergen immunotherapy include the necessary professional services associated with this therapy which includes the monitoring of the injection site and observation of the patient for adverse reactions.
Office visit codes may be billed in addition to immunotherapy only if other significant identifiable services are provided at that time.
Allergen Immunotherapy
Coding
1. Always use the component codes (95115, 95117, 95144-95170) when reporting allergy immunotherapy services to Medicare. Report the injection only codes (95115 and 95117) and/or the codes representing antigens and their preparation (95144-95170). Do not use the complete service codes (95120-95134)!
2. Use CPT component procedure codes 95115 (single injection) and 95117 (multiple injections) to report the allergy injection alone, without the provision of the antigen.
3. Use CPT component procedure codes 95144-95170 (provision of antigens) to report the antigen/antigen preparation service when this is the only service rendered by the physician.
4. Use CPT procedure codes 95115/95117 and the appropriate CPT procedure code from the range 95145-95170 when reporting both the injection and the antigen/antigen preparation service (complete service). These instructions also apply to allergists who provide both services through the use of treatment boards.
5. The provision of antigens must be coded based on the specific type of antigen provided: · CPT code 95144 is used to report regular antigens, other than stinging insect. Use this code to report single dose vials. Use this code only when the allergist actually prepares the extract. Code 95144 (single dose vials of antigen) should be reported only if the physician providing the antigen is providing it to be injected by someone other than himself/herself. If this code is mistakenly reported in conjunction with an injection (95115 or 95117), payment will be made under code 95165.
· CPT procedure code 95165 is used to report multiple dose vials of non-venom antigens. Effective January 1, 2001, for CPT code 95165, a dose is now defined as a one- (1) cc aliquot from a single multidose vial. When billing code 95165, providers should report the number of
units representing the number of 1 cc doses being prepared. A maximum of 10 doses per vial is allowed for Medicare billing, even if more than ten preparations are obtained from the vial. In cases where a multidose vial is diluted, Medicare should not be billed for diluted preparations in excess of the 10 doses per vial allowed under code 95165.
· CPT procedure codes 95145-95149 and 95170 are used to report stinging insect venoms. Venom doses are prepared in separate vials and not mixed together -except in the case of the three vespid mix (white and yellow hornets and yellow jackets). Use the code within the range that is appropriate to the number of venoms provided. If a code for more than one venom is reported, some amount of each of the venoms must be provided. Use of a code below the venom treatment number for the particular patient should occur only for the purpose of “catching up” (see coding guideline # 7).
· The antigen codes (95144-95170) are considered single dose codes. To report these codes, specify the number of doses provided.
· 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.
6. 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.
7. When a venom regimen requires that antigens be mixed from more than one vial for administration and, due to a dose adjustment of one of the antigens, one vial is depleted before the other, the physician may bill for “catch-up” doses of the short antigen. This must be done in a manner that synchronizes the preparation back to the highest venom code possible in the shortest amount of time. To catch up, the physician would bill only the amount of the depleted vial needed to catch-up with the other vials. This will permit the physician to get back to preparing the full number of venoms at one time and billing the doses of the “cheaper” higher venom codes. Use of a code below the venom treatment number for the particular patient should occur only for the purpose of “catching up”
8. A visit to an allergist, which yields a diagnosis of specific allergy sensitivity but does not include immunotherapy, should be coded according to the level of care rendered.
9. Use CPT procedure code 95180 (rapid desensitization) when sensitivity to a drug has been established and treatment with the drug is essential. This procedure will also require frequent monitoring and skin testing. The number of hours involved in desensitization must be reported in the unit’s field.
10. Allergy Shots and Visit Services on Same Day
EXAMPLES:
(1) If a 10cc multidose vial is filled to 6cc with antigen, the physician may bill Medicare for 6 doses since six 1cc aliquots may be removed from the vial.
(2) If a 5cc multidose vial is filled completely, the physician may bill Medicare for 5 doses for this vial.
(3) If a physician removes ½ cc aliquots from a 10cc multidose vial for a total of 20 doses from one vial, he/she may only bill Medicare for 10 doses. Billing for more than 10 doses would mean that Medicare is overpaying for the practice expense of making the vial.
(4) If a physician prepares two 10cc multidose vials, he/she may bill Medicare for 20 doses. However, he/she may remove aliquots of any amount from those vials. For example, the physician may remove ½ aliquots from one vial, and 1cc aliquots from the other vial, but may bill no more than a total of 20 doses.
(5) If a physician prepares a 20cc multidose vial, he/she may bill Medicare for 20 doses, since the practice expense is calculated based on the physician’s removing 1cc aliquots from a vial. If a physician removes 2cc aliquots from this vial, thus getting only 10 doses, he/she may nonetheless bill Medicare for 20 doses because the PE for 20 doses reflects the actual practice expense of preparing the vial.
(6) If a physician prepares a 5cc multidose vial, he may bill Medicare for 5 doses, based on the way that the practice expense component is calculated. However, if the physician removes ten ½ cc aliquots from the vial, he/she may still bill only 5 doses because the practice expense of preparing the vial is the same, without regard to the number of additional doses that are removed from the vial.
DESCRIPTION
Allergy testing, evaluations, and immunotherapy are eligible for coverage according to the schedule of covered services in plan documents. Testing or treatment methods not considered as standard medical procedures are not eligible for coverage.
CODING INFORMATION
ICD-10 Codes that may support medical necessity:
D69.0 Allergic purpura
H10.401 – H10.409 Unspecified chronic conjunctivitis
H10.421 – H10.429 Simple chronic conjunctivitis
H10.44 Vernal conjunctivitis
H16.261 – H16.269 Vernal keratoconjunctivitis, with limbar and corneal
H10.411 – H10.419 Chronic giant papillary conjunctivitis
H10.45 Other chronic allergic conjunctivitis
H10.9 Unspecified conjunctivitis
J30.0 – J30.9 Vasomotor and allergic rhinitis
J31.0 – J31.2 Chronic rhinitis, nasopharyngitis and pharyngitis
J32.0 – J32.9 Chronic sinusitis
J33.0 – J33.9 Nasal polyp
J45.20 – J45.998 Asthma
K52.2 Allergic and dietetic gastroenteritis and colitis
K52.89 Other specified noninfective gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis, unspecified
L20.0 – L20.9 Atopic dermatitis
L22 Diaper dermatitis
L23.0 – L23.9 Allergic contact dermatitis
L24.0 – L24.9 Irritant contact dermatitis
L25.0 – L25.9 Unspecified contact dermatitis
L27.0 – L27.9 Dermatitis due to substances taken internally
L29.8 Other pruritus
L29.9 Pruritus, unspecified
L30.0 – L30.9 Other and unspecified dermatitis
L50.0 Allergic urticaria
L50.1 Idiopathic urticaria
L50.6 Contact urticaria
L50.8 Other urticaria
L50.9 Urticaria, unspecified
L56.4 Polymorphous light eruption
T50.905A-T50.905S Adverse effect of unspecified drugs, medicaments and biological substances
T50.995A-T50.905S Adverse effect of other drugs, medicaments and biological substances
T78.00xA-T78.1xxS Anaphylactic reaction due to food
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Group 1 Paragraph: N/A
Group 1 Codes:
95115 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION
95117 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS
95144 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY, SINGLE DOSE VIAL(S) (SPECIFY NUMBER OF VIALS)
95145 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); SINGLE STINGING INSECT VENOM
95146 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); 2 SINGLE STINGING INSECT VENOMS
95147 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); 3 SINGLE STINGING INSECT VENOMS
95148 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); 4 SINGLE STINGING INSECT VENOMS
95149 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); 5 SINGLE STINGING INSECT VENOMS
95165 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY; SINGLE OR MULTIPLE ANTIGENS (SPECIFY NUMBER OF DOSES)
95170 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY; WHOLE BODY EXTRACT OF BITING INSECT OR OTHER ARTHROPOD (SPECIFY NUMBER OF DOSES)
95180 RAPID DESENSITIZATION PROCEDURE, EACH HOUR (EG, INSULIN, PENICILLIN, EQUINE SERUM)
Allergen Immunotherapy (Medicare excerpts) Billing Guidelines:
CPT procedure code 95165 is used to report multiple dose vials of non-venom antigens. Effective January 1, 2001, for CPT code 95165, a dose is now defined as a one- (1) cc aliquot from a single multidose vial. When billing code 95165, providers should report the number of units representing the number of 1 cc doses being prepared. A maximum of 10 doses per vial is allowed for Medicare billing, even if more than ten preparations are obtained from the vial. In cases where a multidose vial is diluted, Medicare should not be billed for diluted preparations in excess of the 10 doses per vial allowed under code 95165.
CPT procedure codes 95145-95149 and 95170 are used to report stinging insect venoms. Venom doses are prepared in separate vials and not mixed together -except in the case of the three vespid mix (white and yellow hornets and yellow jackets). Use the code within the range that is appropriate to the number of venoms provided. If a code for more than one venom is reported, some amount of each of the venoms must be provided. Use of a code below the venom treatment number for the particular patient should occur only for the purpose of “catching up.”
When a venom regimen requires that antigens be mixed from more than one vial for administration and, due to a dose adjustment of one of the antigens, one vial is depleted before the other, the physician may bill for “catch-up” doses of the short antigen. This must be done in a manner that synchronizes the preparation back to the highest venom code possible in the shortest amount of time. To catch up, the physician would bill only the amount of the depleted vial needed to catch-up with the other vials. This will permit the physician to get back to preparing the full number of venoms at one time and billing the doses of the “cheaper” higher venom codes. Use of a code below the venom treatment number for the particular patient should occur only for the purpose of “catching up.”
The antigen codes (95144-95170) are considered single dose codes. To report these codes, specify the number of doses provided.
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.
Allergy Shots and Visit Services on Same Day
Effective for services provided on or after January 1, 1995, visits may not be paid with allergy injection services 95115 through 95199 unless the visit represents another separately identifiable service. Modifier code -25 is used with the visit code to report the patient’s condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided. Coding Guidelines:
Always use the component codes (95115, 95117, 95144-95170) when reporting allergy immunotherapy services to Medicare. Report the injection only codes (95115 and 95117) and/or the codes representing antigens and their preparation (95144-95170). Do not use the complete service codes (95120-95134)! Use CPT procedure codes 95115 (single injection) and 95117 (multiple injections) to report the allergy injection alone, without the provision of the antigen.
Use CPT procedure codes 95144-95170 (provision of antigens) to report the antigen/antigen preparation service when this is the only service rendered by the physician. Use CPT procedure codes 95115/95117 and the appropriate CPT procedure code from the range 95145- 95170 when reporting both the injection and the antigen/antigen preparation service (complete service).
These instructions also apply to allergists who provide both services through the use of treatment boards.
The provision of antigens must be coded based on the specific type of antigen provided:
CPT code 95144 is used to report regular antigens, other than stinging insect. Use this code to report single dose vials. Use this code only when the allergist actually prepares the extract. Code 95144 (single dose vials of antigen) should be reported only if the physician providing the antigen is providing it to be injected by someone other than himself/herself. If this code is mistakenly reported in conjunction with an injection (95115 or 95117), payment will be made under code 95165.
Use CPT procedure code 95180 (rapid desensitization) when sensitivity to a drug has been established and treatment with the drug is essential. This procedure will also require frequent monitoring and skin testing. The number of hours involved in desensitization must be reported in the unit field. A visit to an allergist, which yields a diagnosis of specific allergy sensitivity but does not include immunotherapy, should be coded according to the level of care rendered.
For place of service the following is covered:
CPT procedure codes 95115, 95117 and 95144 are payable only in an office setting (11). CPT procedure codes 95145-95170 are payable in the office (11) and in a hospital outpatient department (22). These codes are also payable in a skilled nursing facility (31), but only if the physician is present. CPT procedure codes 95060, 95065, 95180 are payable in office (11) and hospital settings (21, 22, 23).
Indications for immunotherapy are determined by appropriate diagnostic procedures coordinated with clinical judgment and knowledge of the natural history of allergic diseases. The following indications are considered medically reasonable and necessary for allergy immunotherapy:
Controlled studies have shown that allergen immunotherapy is effective for patients with Allergic rhinitis, Allergic conjunctivitis, Allergic asthma, and Stinging insect hypersensitivity.
Allergen-induced asthma is an indication for immunotherapy along the guidelines for allergic rhinitis when there is a poor response to environmental control or pharmacologic treatment. Allergen immunotherapy in asthmatic patients should not be initiated unless the patient’s asthma is stable. Patients with severe or uncontrolled asthma are at increased risk for systemic reactions to immunotherapy injections.
The necessity of allergen immunotherapy depends on the Degree to which symptoms can be reduced by medications, Ability of the patient to tolerate possible side effects of the medication, Amount, type and cost of the medications required to control symptoms, Significant exposure to an allergen in which there is a significant level of sensitivity and the pattern of symptoms conform to the pattern of exposure, and Whether conservative therapies (including avoidance) have failed to control the symptoms, or avoidance of the relevant antigen (e.g., dust mites, pollen, and mold) is impractical.
Animal dander sensitivity (epidermal) may respond to immunotherapy. While removal of the offending allergen is recommended, this is often not possible or there may be occupational or other sources of exposure. Antihistamines are used first before immunotherapy but a trial of immunotherapy may be warranted if the antihistamines do not relieve symptoms.
Aeroallergen immunotherapy is indicated for patients with allergic rhinitis due to:
Seasonal pollinosis caused by trees, grasses and weeds.
The treatment of mold-induced rhinitis.
Perennials such as cat and dog dander, dust mite and cockroach.
Standardized dust mite extracts appear effective for immunotherapy. Other environmental allergens (e.g., kapok, jute, feathers, and unstandardized house dust extracts) are of questionable value in immunotherapy, however, and generally should not be used.
Venom immunotherapy is indicated for patients who have a severe systemic anaphylactic reaction after an insect sting and a positive skin test or other documented IgE sensitivity to specific insect venom.
Patients with delayed systemic reactions, with symptoms of anaphylaxis or serum sickness and with a positive skin test or presence of venom specific IgE by in vitro testing are also recommended for treatment.
Rapid desensitization is indicated in cases of allergy to insulin, penicillin and horse serum, as well as sulfonamides, cephalosporins and other commonly used drugs (e.g. aspirin). In patients with a positive history of reaction and with documented skin test reactivity, every effort should be made to avoid the use of these substances. When circumstances require the use of one of these substances, the patient will have to be desensitized. Desensitization may need to be repeated if future circumstances require an additional course of the offending allergen. Full-dose therapy should be initiated immediately after reactions (treated and controlled), requiring strict physician monitoring in a setting with continuous monitoring of vital signs and cardio-respiratory status. In most cases, this can be performed in a physician’s office if a physician trained to treat anaphylaxis is physically present for the entire duration. In cases where the initial reaction was severe, desensitization should be performed in the ambulatory care department of a hospital.
Limitations:
The following allergy immunotherapy are considered investigational and experimental, therefore, are not medically necessary. The effectiveness also has not been established, therefore, these indications will not be covered:
Angioedema.
Food hypersensitivity/allergy.
Intrinsic (non-allergic) asthma.
Migraine headaches.
Non-allergic vasomotor rhinitis.
With the following services, allergy immunotherapy services are considered investigational and experimental, therefore, are not medically necessary. The effectiveness also has not been established, therefore, these indications will not be covered:
Therapy with allergoids or adjuvants.
Therapy via other administration:
Oral or sublingual food immunotherapy*,
Epicutaneous immunotherapy,
Intralymphatic immunotherapy,
Intranasal immunotherapy, or
Sublingual immunotherapy.
Desensitization with commercially available extracts of poison ivy, poison oak, or poison sumac.
Desensitization for hymenoptera sensitivity using whole body extracts, with the exception of fire ant extracts**.
Desensitization with bacterial vaccine (BAC: bacterial, antigen complex, streptococcus vaccine, staphylo-strepto vaccine, serobacterin, staphylococcus phage lysate).
Food allergenic extracts immunotherapy.
Intracutaneous desensitization (Rinkel Injection Therapy, RIT).
Intracutaneous titration.
Neutralization therapy (intradermal and subcutaneous).
Repository emulsion therapy.
Sublingual desensitization***.
Sublingual provocative therapy***.
Urine auto-injection (autogenous urine immunotherapy).
Allergen immunotherapy for the management of skin and mucous membrane disease such as atopic dermatitis, chronic urticaria, and Candida vulvovaginitis.
Postmortem examination for IgE antibodies to identify allergens responsible for lethal anaphylaxis (post mortem work is not-covered by Medicare).
Patients who are mentally or physically unable to communicate clearly with the allergist and those with a history of noncompliance are not good candidates for allergy immunotherapy. If a patient cannot communicate clearly with the physician; it will be difficult for the patient to report signs and symptoms, especially early symptoms, suggestive of systemic reactions.
*Several clinical trials with oral and sublingual immunotherapy demonstrate an increased tolerance to oral food challenge in subjects with food hypersensitivity while receiving therapy. Oral and sublingual food immunotherapy is investigational. At present, the only treatment for food hypersensitivity is avoidance.
**Immunotherapy with whole-body extracts of biting insects or other arthropod is covered only for fire ant extracts.
***Sublingual immunotherapy (SLIT) involves the use of FDA approved allergenic extracts administered orally. In early 2014, the FDA approved oral administration of 3 allergenic extracts, two for grasses and one for ragweed. These extracts are not approved by the FDA for anyone over the age of 65 years. Medicare does not cover sublingual immunotherapy. Effective October 31, 1988, sublingual intracutaneous and subcutaneous provocative and neutralization testing and neutralization therapy for food allergies are excluded from Medicare coverage because available evidence does not show that these tests and therapies are effective. (CMS Pub 100-03 Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, Part 2, Section 110.11 – Food Allergy Testing and Treatment).
Covered for:
|
372.05
|
Acute atopic conjunctivitis
|
|
372.14
|
Other chronic allergic conjunctivitis
|
|
381.00–381.06
|
Acute nonsuppurative (allergic) otitis media
|
|
471.0
|
Polyp of nasal cavity
|
|
471.8
|
Other polyp of sinus
|
|
473.0–473.3
|
Chronic sinusitis
|
|
477.0–477.2
|
Allergic rhinitis
|
|
477.8–477.9
|
Allergic rhinitis
|
|
493.00
|
Extrinsic asthma unspecified
|
|
493.10–493.11
|
Intrinsic asthma
|
|
493.20
|
Chronic obstructive asthma unspecified
|
|
493.90–493.91
|
Asthma unspecified
|
|
691.8
|
Other atopic dermatitis and related conditions
|
|
692.9
|
Contact dermatitis and other eczema, unspecified cause
|
|
693.1
|
Dermatitis due to food taken internally
|
|
989.5
|
Toxic effect of venom
|
|
995.0
|
Other anaphylactic shock not elsewhere classified
|
|
995.21–995.23
|
Unspecified adverse effect of drug, medicinal and biological substance
|
|
995.27
|
Other drug allergy
|
|
995.29
|
Unspecified adverse effect of other drug, medicinal and biological substance
|
|
995.3
|
Allergy unspecified not elsewhere classified
|
|
V14.0–V14.3
|
Personal history of allergy to medicinal agents
|