Billing and Coding: Allergy Immunotherapy

The billing and coding information in this article is dependent on the
coverage indications, limitations and/or medical necessity described in the
associated LCD Allergy Immunotherapy L36408.

**Coding Information**

**Billing Guidelines**

See NCCI edits in _National Correct Coding Initiative Policy Manual for
Medicare Services_ , Chapter 11 - Medicine Evaluation and Management Services
for CPT Codes 90000-99999, Section K - Allergy Testing and Immunotherapy, 3.
_Evaluation and management (E &M) codes reported with allergy immunotherapy
are appropriate only if a significant, separately identifiable service is
performed._ _Obtaining informed consent is included in the immunotherapy
service and shall not be reported with an E &M code._ _If E &M services are
reported, modifier 25 should be utilized._

Non-covered services includes the following: Sublingual Intracutaneous and
subcutaneous Provocative and Neutralization Testing: _Effective October 31,
l988, 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 (NCD) Manual,_ Chapter 1, Part 2 Section 110.11 - Food
Allergy Testing and Treatment (Rev. 1, 10-03-03).

_For services rendered on or after January 1, 1995, all antigen/allergy
immunotherapy services are paid for under the Medicare physician fee
schedule._ (CMS Pub 100-04 _Medicare Claim Processing Manual,_ Chapter 12,
Section 200- Allergy Testing and Immunotherapy, Rev. 2997, Issued: 07-25-14)

_The following policies are effective as of January 1, 1995:   _

  1. __CPT codes 95120 through 95134 are not valid for Medicare. Codes 95120 through 95134 represent complete services, i.e., services that include both the injection service as well as the antigen and its preparation.   __
  2. _Separate coding for injection only codes (i.e., codes 95115 and 95117) and/or the codes representing antigens and their preparation (i.e., codes 95144 through 95170) must be used._

___If both services are provided both codes are billed.___

         _This includes allergists who provide both services through the use of treatment boards.   _

  3. _If a physician bills both an injection code plus either codes 95165 or 95144, A/B MACs (B) pay the appropriate injection code (i.e., code 95115 or code 95117) plus the code 95165 rate. When a provider bills for codes 95115 or 95117 plus code 95144, A/B MACs (B) change 95144 to 95165 and pay accordingly. Code 95144 (single dose vials of antigen) should be billed only if the physician providing the antigen is providing it to be injected by some other entity. Single dose vials, which should be used only as a means of insuring proper dosage amounts for injections, are more costly than multiple dose vials (i.e., code 95165) and therefore their payment rate is higher. Allergists who prepare antigens are assumed to be able to administer proper doses from the less costly multiple dose vials. Thus, regardless of whether they use or bill for single or multiple dose vials at the same time that they are billing for an injection service, they are paid at the multiple dose vial rate.   _

  4. _The fee schedule amounts for the antigen codes (95144 through 95170) are for a single dose. When billing those codes, physicians are to specify the number of doses provided. When making payment, A/B_ _MACs (B) multiply the fee schedule amount by the number of doses specified in the units field.   _

  5. _If a patient 's doses are adjusted, e.g., because of patient reaction, and the antigen provided is actually more or fewer doses than originally anticipated, the physician is to make no change in the number of doses for which he or she bills. The number of doses anticipated at the time of the antigen preparation is the number of doses to be billed. This is consistent with the notes on page 30 of the spring 1994 issue of the American Medical Association's CPT Assistant. Those notes indicate that the antigen codes mean that the physician is to identify the number of doses "prospectively planned to be provided." The physician is to "identify the number of doses scheduled when the vial is provided." This means that in cases where the patient actually gets more doses than originally anticipated (because dose amounts were decreased during treatment) and in cases where the patient gets fewer doses (because dose amounts were increased), no change is to be made in the billing. In the first case, A/B MACs (B) are not to pay more because the number of doses provided in the original vial(s) increased. In the second case, A/B MACs (B) are not to seek recoupment (if A/B MACs (B) have already made payment) because the number of doses is less than originally planned. This is the case for both venom and nonvenom antigen codes. _

  6. __Venom Doses and Catch-Up Billing - 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). A dose of code 95146 (the two-venom code) means getting some of two venoms. Similarly, a dose of code 95147 means getting some of three venoms; a dose of code 95148 means getting some of four venoms; and a dose of 95149 means getting some of five venoms. Some amount of each of the venoms must be provided. Questions arise when the administration of these venoms does not remain synchronized because of dosage adjustments due to patient reaction. For example, a physician prepares ten doses of code 95148 (the four venom code) in two vials - one containing 10 doses of three vespid mix and another containing 10 doses of wasp venom. Because of dose adjustment, the three vespid mix doses last longer, i.e., they last for 15 doses. Consequently, questions arise regarding the amount of "replacement" wasp venom antigen that should be prepared and how it should be billed. Medicare pricing amounts have savings built into the use of the higher venom codes. Therefore, if a patient is in two venom, three venom, four venom or five venom therapy, the A/B MAC (B) objective is to pay at the highest venom level possible. This means that, to the greatest extent possible, code 95146 is to be billed for a patient in two venom therapy, code 95147 is to be billed for a patient in three venom therapy, code 95148 is to be billed for a patient in four venom therapy, and code 95149 is to be billed for a patient in five venom therapy. Thus, physicians are to be instructed that the venom antigen preparation, after dose adjustment, must be done in a manner that, as soon as possible, synchronizes the preparation back to the highest venom code possible. In the above example, the physician should prepare and bill for only 5 doses of "replacement" wasp venom - billing five doses of code 95145 (the one venom code). This will permit the physician to get back to preparing the four venoms at one time and therefore billing the doses of the "cheaper" four venom code. Use of a code below the venom treatment number for the particular patient should occur only for the purpose of "catching up."   __

  7. _Code 95165 Dose - Code 95165 represents preparation of vials of non-venom antigens. As in the case of venoms, some non-venom antigens cannot be mixed together, i.e., they must be prepared in separate vials. An example of this is mold and pollen. Therefore, some patients will be injected at one time from one vial - containing in one mixture all of the appropriate antigens - while other patients will be injected at one time from more than one vial. In establishing the practice expense component for mixing a multidose vial of antigens, we observed that the most common practice was to prepare a 10 cc vial; we also observed that the most common use was to remove aliquots with a volume of 1 cc. Our PE computations were based on those facts. Therefore, a physician's removing 10 1cc aliquot doses captures the entire PE component for the service. _

_This does not mean that the physician must remove 1 cc aliquot doses from a
multidose vial. It means that the practice expenses payable for the
preparation of a 10cc vial remain the same irrespective of the size or number
of aliquots removed from the vial. Therefore, a physician may not bill this
vial preparation code for more than 10 doses per vial; paying more than 10
doses per multidose vial would significantly overpay the practice expense
component attributable to this service. (NOTE: this code does not include the
injection of antigen(s); injection of antigen(s) is separately billable.)_

_When a multidose vial contains less than 10cc, physicians should bill
Medicare for the number of 1 cc aliquots that may be removed from the vial.
That is, a physician may bill Medicare up to a maximum of 10 doses per
multidose vial, but should bill Medicare for fewer than 10 doses per vial when
there is less than 10cc in the vial._

_If it is medically necessary, physicians may bill Medicare for preparation of
more than one multidose vial._

  _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 12 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 12 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 12 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. _

**_Allergy Shots and Visit Services on the Same Day_**

_At the outset of the physician fee schedule, the question was posed as to
whether visits should be billed on the same day as an allergy injection (CPT
codes 95115-95117), since these codes have status indicators of A rather than
T. Visits should not be billed with allergy injection services 95115 or 95117
unless the visit represents another separately identifiable service. This
language parallels CPT editorial language that accompanies the allergen
immunotherapy codes, which include codes 9515 and 95117. Prior to January 1,
1995, you appeared to be enforcing this policy through three (3) different
means:_

  * _Advising physician to use modifier 25 with the visit service;_
  * _Denying payment for the visit unless documentation has been provided; and_
  * _Paying for both the visit and the allergy shot if both are billed for._

_For services rendered on or after January 1, 1995, you are to enforce the
requirement that visits not be billed and paid for on the same day as an
allergy injection through the following means. Effective for services rendered
on or after that date, the global surgery policies will apply to all codes in
the allergen immunotherapy series, including the allergy shot codes 95115 and
95117. To accomplish this, CMS changed the global surgery indicator for
allergen immunotherapy codes from XXX, which meant that the global surgery
concept did not apply to those codes, to 000, which means that the global
surgery concept applies, but that there are no days in the postoperative
global period._

_Now that the global surgery policies apply to these services, you are to rely
on the use of modifier 25 as the only means through which you can make payment
for visit services provided on the same day as allergen immunotherapy
services. In order for a physician to receive payment for a visit service
provided on the same day that the physician also provides a service in the
allergen immunotherapy series (i.e., any service in the series from 95115
through 95199), the physician is to bill a modifier 25 with the visit code,_
indicating that the _patient 's condition required a significant, separately
identifiable visit service above and beyond the allergen immunotherapy service
provided. _

Evaluation and Management services are allowed in addition to 95115 or 95117
only when separately identifiable services are provided at the same time.

CPT codes 95115 (single injection) and 95117 (multiple injections) reflect the
professional administration (injection) of the allergenic extract, when the
extract is not included in the code descriptor. They do not include the
provision or preparation of the extract. For example: An allergist provides a
patient with an allergenic extract. The patient brings the extract to a family
or primary care practitioner who administers the injection(s). Do not bill CPT
code 95115 and 95117 if the antigen is self-administered by the patient. Bill
one CPT code 95115 or 95117 per date of service (DOS) and 1 unit in Box 24-G,
days, or unit field. Do not bill CPT code 95115 and 95117 on the same DOS.

Use CPT procedure codes 95115 or 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.

CPT code 95165 includes single OR multiple antigens preparation but not the
administration of the injection(s). Therefore, when a physician prepares the
allergenic extract(s) (same or different antigens) and administers the
extract(s) using single or multiple injections, code 95165 should be reported
in addition to either 95115 or 95117. To bill for 95165, the number of doses
must be designated.

If a physician prepares the allergen and administers the injection on the same
DOS, bill the appropriate injection code (CPT codes 95115 or 95117) AND the
appropriate preparation (single dose) code (CPT codes 95145-95170). For
billing, need to specify the number of doses in the days/units field.

CPT code 95170 can **only** be used for billing for fire ant extract.

A single dose vial contains a single dose of antigen administered in one
injection.

For allergy immunotherapy reporting, a dose is the amount of antigen(s)
administered in a single injection from a multiple dose vial. If a multi-dose
vial contains less than 10 cc, bill the number of 1 cc aliquots that may be
removed from the vial up to a maximum of 10 doses per multi-dose vial. If
medically necessary, physicians may bill for preparation of more than one
multi-dose vial. The reason(s) it is medically necessary must be documented in
the medical record.

Claims for maintenance allergy immunotherapy require the EJ modifier.

**Coding Guidelines**

Allergen immunotherapy is divided into codes that describe the injection only
and codes that describe the preparation of the antigen to be delivered for
injection by a different physician.

See NCCI edits in _National Correct Coding Initiative Policy Manual for
Medicare Services_ , Chapter 11 - Medicine Evaluation and Management Services
for CPT Codes 90000-99999, Section K - Allergy Testing and Immunotherapy, 4.
_In general a_ _llergy testing is not performed on the same day as allergy
immunotherapy in standard medical practice. Allergy testing is performed prior
to immunotherapy to determine the offending allergens. CPT codes for allergy
testing and immunotherapy are generally not reported on the same date of
service unless the physician provides allergy immunotherapy and testing for
additional allergens on the same day. Physicians should not report allergy
testing CPT codes for allergen potency (safety) testing prior to
administration of immunotherapy. Confirmation of the appropriate potency of an
allergen vial for immunotherapy is an inherent component of immunotherapy.
Additionally, allergy testing is an integral component of rapid
desensitization kits (CPT code 95180) and is not separately reportable._

_Codes 95115-95199 include the professional services necessary for allergen
immunotherapy. Office visits codes may be used in addition to allergen
immunotherapy if other identifiable services are provided at the same time._

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits.
This policy does not take precedence over CCI edits. Please refer to the CCI
for correct coding guidelines and specific applicable code combinations prior
to billing Medicare.

_CPT codes 95120 through 95134 are not valid for Medicare. Codes 95120 through
95134 represent complete services, i.e., services that include both the
injection service as well as the antigen and its preparation._ (CMS Pub 100-04
_Medicare Claim Processing Manual_ , Chapter 12 - Physicians/Nonphysician
Practitioners, Section 200 - Allergy Testing and Immunotherapy.

_Use CPT procedure codes 95144-95170 (provision of antigens) to report the
antigen/antigen preparation service (professional services) when this is the
only service rendered by the physician_. _Which code is used is based on the
specific type of antigen provided:_

_CPT code 95144 is used to report 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" __

_The antigen codes (95144-95170) are considered single dose codes. To report
these codes, specify the number of doses provided._

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.

**Place of Service**

CPT procedure codes 95115 and 95117 are payable only in an office setting.

CPT procedure codes 95144 and 95145-95170 are payable in the office and
outpatient hospital (off-campus/on-campus) settings. These codes are also
payable in a skilled nursing facility, but only if the physician is present.

CPT procedure code 95180 is payable in office, outpatient hospital (off-campus
/ on-campus), inpatient hospital, and emergency room settings.

**Antigens**

_Effective January 1, 1981, payment may be made for a reasonable supply of
antigens that have been prepared for a particular patient even though they
have not been administered to the patient by the same physician who prepared
them if:_

  * _The antigens are prepared by a physician who is a doctor of medicine or osteopathy, and_
  * _The physician who prepared the antigens has examined the patient and has determined a plan of treatment and a dosage regimen._

_A reasonable supply of antigens is considered to be not more than a 12-month
supply of antigens that has been prepared for a particular patient at any one
time._ (CMS Pub 100-02 _Medicare Benefit Policy Manual,_ Chapter 16 - General
Exclusions from Coverage, Section 90 - Routine Services and Appliances, B.
Antigens, Rev. 186, Issued: 04-16-2014, _the purpose of the reasonable supply
limitation is to assure that the antigens retain their potency and
effectiveness over the period in which they are to be administered to the
patient._ (See the CMS Pub _Medicare Benefit Policy Manual,_ Chapter 15,
"Covered Medical and Other Health Services," 50.4.4.1).