Allergists commonly bill CPT code 95165, which describes services for the supervision of preparation and provision of antigens for allergen immunotherapy. It is important that allergists understand the Medicare definition of a “dose” before billing CPT code 95165 for Medicare patients. Medicare defines a dose, for billing purposes only, as 1cc of extract and does not cover dilutions. Medicare reimbursement is based on this definition.
The practice expense (PE) inputs for CPT code 95165 are based on an assumption that ten doses are included in each 10cc vial of antigens. Under Medicare’s definition of a “dose,” an allergist removing ten 1cc aliquot doses captures the entire PE component for the service. Accordingly, if an allergist prepares a 10cc multidose maintenance vial, the allergist may bill a maximum of 10 doses to Medicare.
This is true even if the allergist obtains more than 10 doses from each multidose vial. The definition of a dose is for billing purposes only and does not dictate the allergist’s treatment. However, if the physician removes .5cc aliquots from a 10cc multidose vial for a total of 20 doses from one vial, the physician may only bill Medicare for 10 doses.
A multidose vial may contain less than 10cc. In that scenario, the physician should bill Medicare for the number of 1cc aliquots that are removed from the vial. If an allergist prepares a 5cc multidose vial, he or she may only bill a maximum of five doses under CPT code 95165.
If medically necessary, allergists may bill for more than one multidose vial so long as they document the reasons it is medically necessary in the medical record.
In addition, Medicare has assigned medically unlikely edits (MUEs) of 30 units per day for CPT code 95165. The MUEs are the maximum unit(s) of service that could be reported for a single beneficiary on the same date of service for the vast majority of appropriately reported claims. Claims in excess of the MUE number of units are considered “medically unlikely.”
Some Medicaid agencies and private payers have also started to follow Medicare’s rules on allergy immunotherapy. Notably, the Advocacy Council opposes the use of these Medicare definitions by other payers. The CPT descriptors for 95165 require billing by the number of doses – not the number of ccs.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
