BILLING CPT 95165 - professional services

Specific to allergy testing and treatment services (CPT codes 95004 and 95165), please see below:

CPT code 95004 is defined as “Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests.” (2013, AMA CPT Professional Edition, p. 529)  A physician may delegate, with appropriate supervision, the performance of certain procedures and/or components of procedures for efficient use of physician, staff and patient time. Although a physician may delegate certain physical tasks of allergy testing, the definition of 95004 requires the physician to personally review the allergy test results -- either by inspecting the test site(s) on the patient or analyzing a detailed report of the objective test findings. Then, using this personal test result review and taking the patient’s full medical history (including known allergies and occurrence of allergy- related conditions such as rhinitis and sinusitis) into account, the physician decides if the patient is an appropriate candidate for immunotherapy. This personal review and determination should be documented in the patient’s medical record to fully satisfy the “report” requirements of this code.

CPT Code 95165 is defined as “Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses).”  (2013, AMA CPT Professional Edition, p. 531) A physician may delegate, with appropriate supervision, the performance of certain procedures and/or components of procedures for efficient use of physician, staff and patient time. A physician may delegate the tasks of physical antigen/serum mixing, patient instruction for serum injection, and providing serum vials to the patient. However, after determining a patient is an appropriate candidate for immunotherapy (as described above) the physician must personally select the allergens for immunotherapy, determine the specific concentrations and dilutions, and order the specific shot schedule. The physicians must also personally monitor the patient’s progress throughout the course of immunotherapy and not merely delegate that responsibility to ancillary (third party vendor) personnel.

In addition, BCBSTX limits payment for allergy serum to the amount actually provided to the patient on a given date of service but no more than 60 units per two (2) months.  This policy does not apply to rapid desensitization.

CPT Code 95165

Medicare allowed approximately $98 million in charges for allergen immunotherapy codes in 2000. Nearly half of these charges, $47 million, were for CPT code 95165, professional services for the provision of antigens for allergen immunotherapy; single or multiple antigens, per dose. This code describes the preparation of antigen serums for use in immunotherapy, but not their injection. General allergists submitted about two-thirds of the claims for CPT code 95165, and ENT allergists account for about 20 percent. Most of the remainder come from internists, general practitioners, family doctors, and various group practices. Although per unit allowed charges are fairly constant across different specialties, ENT allergists bill more units (and receive greater reimbursement) per claim than other specialties

The interpretation of CPT code 95165 has been controversial. The code is unlike others in that it includes the concept of a ‘dose,’ which is not defined in the CPT manual. Traditionally, providers and payers defined a dose as the amount of antigen given in a single injection. In May 1998, CMS updated the carrier manual to define a dose as “the total amount of antigen to be administered to a patient during one treatment session, whether mixed or in separate vials.” Private payers, however, did not adopt this change; as a result, they paid 590 percent more per unit of CPT code 95165 than Medicare in 1999.2 After this change was instituted, the Relative Value Scale Update Committee recommended that CMS return to the traditional definition for the 1999 fee schedule update. At the time, though, CMS did not feel a revision was appropriate because the Committee failed to comment on the direct practice expense inputs to the code. In November 2000, after receiving many comments from specialty organizations, CMS revised the inputs for CPT code 95165. In this revision, effective January 1, 2001, CMS defines a dose, for billing and practice expense calculations, as “a one cc aliquot [part] from a single multidose vial.”3 All practice expense inputs for CPT code 95165 are based on this definition, although no allocation is made for resources and work used to create treatment or dilution boards.

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