Article - Billing and Coding: Allergy Immunotherapy (A57472)

CMS National Coverage PolicyItalicized font represents CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.Title XVIII of the Social Security Act, Section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, Section 1862 (a) (1) (A) allows coverage and payment of those items or services that are considered to bemedically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, Section 1862 (a) (1) (D) excludes investigational or experimental from Medicare coverage.42 CFR Section 410.68  Antigens: Scope and Conditions. This section describes thatMedicare Part B pays for (a) antigens that are furnished as services incident to a physicians professional services; or (b) a supply of antigen sufficient for not more than 12 months that is.It describes who prepares, administers, and supervises.CMS Pub 100-02Medicare Benefit Policy Manual, Chapter 15  Covered Medical and Other Health Services, Sections20.2  Physician Expense for Allergy Treatment,50.4.4.1  Antigens,60.2  Services of Nonphysician Personnel Furnished Incident to Physicians Services80.1  Clinical Laboratory Services, and80.6  Requirements for Ordering and Following Orders for Diagnostic Tests.Chapter 16  General ExclusionsFrom Coverage, Section90  Routine Services and Appliances, B. Antigens.CMS Pub 100-03Medicare National Coverage Determinations (NCD) Manual, Chapter 1  Coverage Determinations, Part 2, Sections110.9  Antigens Prepared for Sublingual Administration110.11  Food Allergy Testing and TreatmentCMS Pub 100-04Medicare Claims Processing Manual, Chapter 12  Physicians/Nonphysician Practitioners, Section200 - Allergy Testing and Immunotherapy, andChapter 16  Laboratory Services, Section40.7  Billing for Noncovered Clinical Laboratory Tests.Article TextThe 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 InformationBilling GuidelinesSee NCCI edits inNational 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 100-03Medicare 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 100-04Medicare 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: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.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.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.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/BMACs (B) multiply the fee schedule amount by the number of doses specified in the units field.If a patients 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 Associations 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.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.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 physicians 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.