CPT CODES - 95115, 95117, 95165 - 95180 and Allergen Immunotherapy


Procedure code and description

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


CMS National Coverage Determinations for allergen immunotherapy include the provision that only injected antigens are covered by Medicare. Non-injected antigens and professional services associated with preparation of non-injected antigens must not be reported to Medicare for payment as injected antigens.
For injected antigens, Medicare will allow coverage for under the following conditions:
  • Diagnosed hypersensitivity to a substance indicated by the appropriate ICD-9-CM code(s) listed in this policy.
  • Hypersensitivity that cannot be managed by a medication or avoidance.
  • The allergens should be prepared for the patient individually
  • The allergen content should be based on appropriate skin testing, or appropriate in vitro testing.
Compliance with the provisions in this policy is subject to monitoring by postpayment data analysis and subsequent medical review.
Limitations:
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
 Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • 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.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 21X, 22X, 23X, 71X, 83X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
95115© 
Immunotherapy, one injection
95117© 
Immunotherapy injections
95144© 
Antigen therapy services
95145© 
Antigen therapy services
95146© 
Antigen therapy services
95147© 
Antigen therapy services
95148© 
Antigen therapy services
95149© 
Antigen therapy services
95165© 
Antigen therapy services
95180© 
Rapid desensitization

ICD-9-CM Codes that Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, 95165 and 95180:
Covered for:
372.05
Acute atopic conjunctivitis
372.14
Other chronic allergic conjunctivitis
381.00381.06
Acute nonsuppurative (allergic) otitis media
471.0
Polyp of nasal cavity
471.8
Other polyp of sinus
473.0473.3
Chronic sinusitis
477.0477.2
Allergic rhinitis
477.8477.9
Allergic rhinitis
493.00
Extrinsic asthma unspecified
493.10493.11
Intrinsic asthma
493.20
Chronic obstructive asthma unspecified
493.90493.91
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
995.21995.23
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
V14.0V14.3
Personal history of allergy to medicinal agents
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses that DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

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