What do you know about 95165?

Communications we have received recently from members suggest there may still be some confusion as to Medicare rules for allergy immunotherapy billing (CPT Code 95165). 

There has been no change in Medicare’s policy which has been in place for several years.  

Medicare defines a dose, for billing purposes only, as 1cc of extract and it does not pay for diluted vials made from the concentrated vial. This policy  is set forth in Ch. 12, Section 200 of the Medicare Claims Processing Manual. It explains that the Medicare payment amount is based on the cost of antigens in one cc of a concentrated or maintenance vial.

Most Medicaid and private plans have not adopted this policy.

We continue to believe that payers should follow CPT guidance - which defines a dose as the amount of antigen administered in a single injection from a multi-dose vial or drawn from a treatment board in one syringe.

If you have concerns that a private plan or Medicaid managed care plan is adopting Medicare’s rules, rather than the CPT definition of dose, please contact the Advocacy Council. We may be able to help you address the issue with the payer.

For other questions on CPT 95165, view one of the College’s most well-attended webinars, Everything you wanted to know about CPT 95165, recently presented live to more than 400 attendees.

Advocacy Issue: 
Mixing Allergen Extracts
Billing, Coding & Payments