(Medicare Claims Processing Manual)

7. Code 95165 Doses . -  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 pati ents 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 physicians remo ving 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 doe s 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  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  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 physicians removing 1cc aliquots from a vial.  If a physician removes 2cc aliquots from this vial, thus getting onl y 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  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.   C. 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 bi lled 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 gl obal 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 t he visit code, indicating that the patients condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided.   D. Reasonable Supply of Antigens   See CMS Manual System, Internet Only Manual, Medicare Benefits Policy Manual, CMS Pub. 100- 02 Chapter 15, section 50.4.4, regarding the coverage of antigens, including what constitutes a reasonable supply of antigens.  210 - Outpatient Mental Health Treatment Limitation  (Rev. 2166, Issued: 02- 25-11, Effective: 03 -25-11, Implementation: 03- 25-11)  Regardless of the actual expenses a beneficiary incurs in connection with the treatment of mental, psychoneurotic, and personality disorders while the beneficiary is not an inpatient of a hospital at the time such expenses are incurred, the amount of those  expenses that may be recognized for Part B deductible and payment purposes is limited to 62.5 percent of the Medicare approved amount for those services.  This limitation is called the outpatient mental health treatment limitation (the limitation).  The 6 2.5 percent limitation has been in place since the inception of the Medicare Part B program and it will remain effective at this percentage amount until January 1, 2010.  However, effective January 1, 2010, through January 1, 2014, the limitation will be phased out as follows:    January 1, 2010 -  December 31, 2011, the limitation percentage is 68.75%.  (Medicare pays 55% and the patient pays 45%).    January 1, 2012 -  December 31, 2012, the limitation percentage is 75%.  (Medicare pays 60% and the patient pays 40%).    January 1, 2013 -  December 31, 2013, the limitation percentage is 81.25%.  (Medicare pays 65% and the patient pays 35%).    January 1, 2014 -  onward, the limitation percentage is 100%. (Medicare pays 80% and the patient pays 20%).   For additional details concerning computation of the limitation, please see the examples under section 210.1 E.   210.1 - Application of the Limitation  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)    A. Status of Patient    The limitation is applicable to expenses incurred in connection with the treatment of an individual who is not an inpatient of a hospital.  Thus, the limitation applies to mental health services furnished to a person in a physicians office, in the patient s home, in a skilled nursing facility, as an outpatient, and so forth.  The term hospital in this context means an institution, which is primarily engaged in providing to inpatients, by or under the supervision of a physician(s):     Diagnostic and therapeutic services for medical diagnosis, treatment and care of injured, disabled, or sick persons;     Rehabilitation services for injured, disabled, or sick persons; or     Psychiatric services for the diagnosis and treatment of mentally ill patients.    B. Disorders Subject to the Limitation    The term mental, psychoneurotic, and personality disorders is defined as the specific psychiatric diagnoses described in the International Classification of Diseases, 9th Revision (ICD -9), under the code range 290-319.    When the treatment services rendered are both for a psychiatric diagnosis as defined in the ICD -9 and one or more nonpsychiatric conditions, separate the expenses for the psychiatric aspects of treatment from the expenses for the nonpsychiatric aspects of treatment.  However, in any case in which the psychiatric treatment component is not readily distinguishable from the nonpsychiatric treatment component, all of the expenses are allocated to whichever component constitutes the primary diagnosis.    1. Diagnosis Clearly Meets Definition -  If the primary diagnosis reported for a particular service is the same as or equivalent to a condition described in the ICD9 under the code range 290- 319 that represents mental, psychoneurotic and personality disorders, the expense for the service is subject to the limitation except as described in subsection D.    2. Diagnosis Does Not Clearly Meet Definition -  When it is not clear whether the primary diagnosis reported meets the definition of mental, psychoneurotic, and personality disorders, it may be necessary to contact the practitioner to clarify the diagnosis.  I n deciding whether contact is necessary in a given case, give consideration to such factors as the type of services rendered, the diagnosis, and the individuals previous utilization history.    C. Services Subject to the Limitation    A/B MACs (B) must apply the limitation to claims for professional services that represent mental health treatment furnished to individuals who are not hospital inpatients by physicians, clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists and physician assistants.  Items and supplies furnished by physicians or other mental health practitioners in connection with treatment are also subject to the limitation.    Generally, A/B MACs (B) must apply the limitation only to treatment services.   However, diagnostic psychological and neuropsychological testing services performed to evaluate a patients progress during treatment are considered part of treatment and are s ubject to the limitation.    D. Services Not Subject to the Limitation    1. Diagnosis of Alzheimers Disease or Related Disorder -  When the primary diagnosis reported for a particular service is Alzheimers Disease or an Alzheimers related disorder, A/B MACs (B) must look to the nature of the service that has been rendered in det ermining whether it is subject to the limitation.  Alzheimers disease is coded 331.0 in the International Classification of Diseases, 9th Revision, which is outside the code range 290- 319 that represents mental, psychoneurotic and personality disorders.  Additionally, Alzheimers related disorders are identified by A/B MACs (B) under ICD -9 codes that are within the 290- 319 code range (290.XX or others as A/B MACs (B) determine appropriate) or outside the 290- 319 code range as determined appropriate by A/ B MACs (B).  When the primary treatment rendered to a patient with a diagnosis of Alzheimers disease or a related disorder is psychotherapy, it is subject to the limitation.  However, typically, treatment provided to a patient with a diagnosis of Alzheimers Disease or a related disorder represents medical management of the patients condition (such as described under  CPT code 90862 or any successor code) and is not subject to the limitation.   CPT code 90862 describes pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy.