Immunologists, have you ever taken pride in what you do? If not, you should! Because every vial that you prepare for allergen immunotherapy is a calculated step that relieves the patient from the symptoms and reduces the allergen’s impact.
However, translating that into precise coding and billing requires an understanding of the specific code, varying payer policies, modifier application, and documentation requirements. We understand the struggles. Therefore, this guide will serve as a go-to resource whenever you need to bill CPT code 95165.
Read it till the end to capture the value of every antigen you prepare!
CPT Code 95165 – Description
Before we get into the billing and reimbursement guidelines related to CPT code 95165, it is essential to understand what the code covers.
Believe it or not, but understanding the descriptor of any procedural code is the first step towards precisely reporting it. It helps you avoid denials, underpayments, and audits. So, without further ado, let’s comprehend the CPT 95165 descriptor.
It covers the mixing and preparation of the antigens (one or several) for allergen immunotherapy.
For context, allergen immunotherapy is a medical treatment that aims to minimize allergy symptoms by modifying the patient’s immune system’s response to specific allergens. It is also known as desensitization.
Note: CPT code 95165 does not include the antigen administration.
Scenarios Where CPT Code 95165 is Applicable
Here are some real-world clinical scenarios to help you understand where this CPT code applies:
Initial Antigen Preparation
Picture a patient with newly diagnosed seasonal allergies to multiple pollens, such as those produced by weeds, grass, and trees. The allergist conducts extensive allergen testing and, based on specific sensitivities, orders a custom allergy extract.
Therefore, the medical assistant prepares a series of antigen vials under the direct supervision of the allergist (CPT code 95165). These are essential to start the allergen immunotherapy for the patient’s initial build-up phase. Besides, the custom antigen vials will ensure precise dilution and labeling for the upcoming allergy injections.
Maintenance Vial Preparation
Consider a patient who has been receiving allergen immunotherapy injections for the last two years. The patient has reached his maintenance phase, and the current antigen vials have almost ended.
Therefore, the allergist reviews the patient’s progress and tolerance levels. Based on the findings, he confirms the continuation of the current antigen mix. As a result, a new set of maintenance contraction antigen vials is prepared following the allergist’s specific instructions.
Here, the allergist will report CPT code 95165 for the antigen preparation.
Adjusted Antigen Preparation
Imagine a patient receiving immunotherapy for perennial allergies to cat dander and dust mites. The patient is reaching the maintenance dosage. However, he complains of experiencing persistent symptoms.
Therefore, the allergist performs tests and re-evaluates the patient’s condition. Based on the results, he increases the concentration of the cat dander antigen and modifies the dust mite mix.
The allergist then supervises the precise mixing and preparation of new, adjusted antigen vials (CPT code 95165) as per the revised treatment plan.
Applicable Modifiers for CPT Code 95165
What happens when, during the preparation of the antigen, the physician renders additional distinct and separate services that are unrelated to the allergen immunotherapy?
You append modifier 25 with an appropriate evaluation and management (E/M) office visit code. However, the documentation must support that the additional services are significant and eligible for a separate reimbursement.
CPT Code 95165 – Billing & Reimbursement Guidelines
Discussed below are the essential billing and reimbursement guidelines related to CPT 95165:
Pay Attention to Unit Limits and Reporting
Insurance payers allow you to bill a maximum of 150 units of 95165 (per provider). However, the annual threshold for reporting CPT code 95165 is 250 units in a calendar year. Besides, it includes all provider code submissions.
The unit value reported for CPT 95165 must reflect the actual number of doses that the physician plans to administer during the treatment period.
But, what happens when the doses are adjusted or diluted, i.e., the prepared antigen results in fewer or more doses than originally anticipated? You cannot change the number of doses for which the physician initially billed CPT code 95165.
For the unversed, Medicare defines a ‘dose’ as the amount of antigen the provider administers in a single syringe.
Also note that Medicare allows providers to bill a maximum of 10 doses per vial, even if more than 10 doses are later obtained from the vial through dilution.
Follow the Documentation Requirements
Comprehensive documentation helps you avoid negative consequences, such as claim denials and audits. It also helps demonstrate the medical necessity of the billed service. As a result, you ensure faster claim processing and timely reimbursement.
Therefore, when billing for CPT code 95165, you must include the following:
- Mention the date of mixing and preparation of antigens.
- State the number of doses prepared under the physician’s supervision.
- Patient symptoms and diagnoses.
- Laboratory tests and their findings.
- Proposed treatment plan details.
Understand Payer-Specific Policies
There is no one-size-fits-all solution when it comes to insurance policies. Payer guidelines often vary significantly in terms of reimbursement rates, billing requirements, and even allowable frequency.
Therefore, you must strive to review the relevant payer policies while reporting CPT code 95165. You can either contact the payer directly or browse through online portals. Additionally, some billing software and EHR systems integrate payer-specific rules to speed up the process.
Why is it necessary? Because non-compliance with payer policies results in straight denials, straining your practice’s revenue cycle.
Summary
With that said, it is time to wrap up this guide. However, before concluding, why not summarize the key takeaways? It will offer a quick summary and make everything we discussed more digestible.
So, here we go!
First, we explained the CPT code 95165’s descriptor. It covers the preparation of one or several antigens for allergen immunotherapy. Next, we shared some real-world clinical scenarios. These include initial antigen preparation, maintenance vial preparation, and adjusted antigen preparation.
Moreover, we discussed that if the physician renders additional significant services while supervising the antigen preparation, then you should report the relevant E/M code with modifier 25. Finally, we explained the key billing and reimbursement guidelines.
Are you still unsure about handling billing for antigen preparation services in-house? Don’t worry, partner with MediBillMD for professional immunology billing services.
