CPT 95165 can be used to report professional services for the supervision of preparation and provision of antigens for allergen immunotherapy. Underneath the description, billing guidelines and reimbursement for this code.
95165 CPT Code Description
CPT 95165 can be billed for professional services for the supervision of preparation and provision of antigens for allergen immunotherapy.
CPT code 95165 can be used for multiple antigens or a single antigen. The number of doses needs to be specified.
The 95165 CPT code is defined as:
“Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy. Multiple antigens or single antigent. Specify number of doses.”
CPT 95165 Billing Guidelines
Allergy services are divided into three components and need to be considered while coding CPT 95165:
- Allergy testing
- Professional service of preparation and provision of antigens for allergen immunotherapy
- Administration of allergy immunotherapy (allergy shot(s))
Preparation and provision of antigens for allergen immunotherapy is performed once the patient has gone through allergy testing and it has been determined that the patient has allergies to one or more substances.
The antigens for allergen immunotherapy are then prepared using the results of the allergy testing.
The goal of the immunotherapy is to desensitize the patient to the elements to which the patient is allergic.
The desensitization process involves administering very diluted antigens via injection, gradually building up to a maintenance dose over time.
CPT code 95165 requires the amout of doses to be specified. The doses leading to the maintenance dose are all diluted by a significant amount of sterile saline.
Dosage vials are initially prepared with maintenance doses of the antigens. A small amount of the maintenance dilution is placed into another vial. That vial is then filled to capacity (e.g., 10 cc) with diluent.
This vial will have a different color top from the maintenance vial. A small amount of the diluted antigen from the second vial is withdrawn and placed in a third vial, which is also filled to capacity with diluent.
There are examples where some allergy preparations will continue this progression until seven vials, or 70 cc, of maintenance and diluted antigens are prepared.
The description of CPT 95164 describes this process says to “specify number of doses.” This means that you need to know how much antigen and diluent is drawn up into the syringe to make up a “dose.”
You also need to know what the payer defines as a dose, as they may override the actual dose that is administered for a “reimbursable dose” definition specific to that payer.
Medicare Part B has medically unlikely edit (MUE) of any amount above 30 units to recognize that different vials of maintenance antigens can be made up for antigens that cannot be mixed together and must be kept separate.
A patient who was given 30 units of CPT 95165 received three shots. A patient who received 20 units of CPT 95165 was given two shots.
Do not bill Medicare Part B for 20 or 30 units of diluted vials. The 20 or 30 units should only be billed to Medicare Part B if the patient has allergies such that the antigens cannot be mixed and must be kept separate in two vials (20 units) or three vials (30 units).
CPT Code 95165 Reimbursement
Reimbursement for CPT 95165 is very specific due to the restrictive definition of a “dose” by medicare.
No other payerhas this same definition, stating in the Medicare Physician Fee Schedule final rule that a “dose” is 1 cc aliquot of maintenance antigen. Medicare Part B will not pay for diluent beyond what is needed to create the maintenance antigen.
In the above example, where the three vials were created, two vials diluted from a maintenance vial, giving 30 cc of antigen, Medicare Part B would only pay for the original vial of non-diluted maintenance antigen — 10 units for the 10 cc in that vial.
Even if the patient is receiving 0.5 cc shots, meaning each vial provides 20 allergy shots, Medicare Part B only recognizes 1 cc doses.
As a result, only 10 units will be reimbursed. In the example above, where allergy operations make up seven vials, or 70 cc of antigen, you can only bill Medicare Part B for 10 units for the one maintenance dose vial.