The Advocacy Council regularly receives queries from members on how to correctly code specific scenarios. Recently we received a request asking:
Q: What are our billing options if we have to make new vials for patients for reasons such as: noncompliance in getting their shots, missed shots because of illness, someone in the office dropped and broke vials, or mishandling at a student health services office?
Can we bill insurance for extra doses? Can we bill patients for extra doses?
A: You may have several options to choose from when extract vials need to be remixed:
- If a patient is noncompliant, you can bill insurance the same way you’d bill any other doses. Just be sure to document why the extra doses are needed.
- If the insurer denies payment (for example, if it exceeds the annual limit), then review your insurance contract to determine whether you can bill the patient.
- Billing for dropped or mishandled vials is a business decision. It falls into the same category as whether you charge a patient when you treat them for a systemic reaction caused by an allergy shot.
- Is it worth the public relations risk – alienating the patient (and/or family) for future care?
- It’s important to consider that “billing the insurance” may leave the patient with a copay, of if they have a high deductible, the entire cost of the extract vial.
- If you decide to charge for the remix, you will use CPT code 95165 X the number of units you anticipate administering.
- Document medical necessity in the chart and (if needed) on the claim – for example: “Previously prepared AIT vials found frozen at student health center; extracts nonviable; remixed per safety guidance.”
- Attach/keep evidence (e.g., photo of frozen vials, temperature log, note from student health) in case of payer audit.
- Expect payer variation: Some plans will pay for the remake; others consider replacement the responsibility of the party that damaged the vials. If denied as “replacement,” you can appeal with documentation or bill the responsible party per your financial policy.
- This is the opportune time for the practice to ensure all the proper handling instructions are included on their “send out” vials, including that the antigen cannot be frozen.
Do you have a coding conundrum of your own? Share it with us!
