DRAFT LCD Reference Article Billing and Coding Article

Billing and Coding: Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)

DA59976

Expand All | Collapse All
Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

Document Note

Note History

Contractor Information

Draft Article Information

General Information

Source Article ID
N/A
Draft Article ID
DA59976
Original ICD-9 Article ID
Not Applicable
Draft Article Title
Billing and Coding: Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)
Article Type
Billing and Coding
Original Effective Date
N/A
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2024 American Dental Association. All rights reserved.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §20.2 Physician Expense for Allergy Treatment and §50.4.4.1 Antigens

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §200 Allergy Testing and Immunotherapy

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Allergen Immunotherapy with Subcutaneous Immunotherapy LCD ID# DL40050.

95165 - Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses). These codes report the physician's preparation of an antigen for allergen immunotherapy and the provision of the antigen extract itself. These codes also include the providing physician's calculations for the concentration and volume to be used in the dosage based upon the patient's previous skin test results and personal history. These codes do not, however, include the administration of the allergen therapy. The number of doses must be specified and the vial(s) (series of vials from a treatment regimen or 1 multiple dose vial) from which the dose may be drawn is irrelevant. Report the code based on the type of antigen(s) prepared. See further details below.

Code 95165 Doses - Code 95165 represents preparation of vials of non-venom antigens.

In establishing the practice expense (PE) component for mixing a multidose vial of antigens, it was observed that the most common practice was to prepare a 10-cc vial; it was also observed that the most common use was to remove aliquots with a volume of 1 cc. The PE computations were based on those facts. Therefore, a physician’s 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 PEs payable for the preparation of a 10-cc 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 PE 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 10 cc, 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 10 cc in the vial. If it is medically necessary, physicians may bill Medicare for preparation of more than 1 multidose vial.

EXAMPLES:

  1. If a 10 cc multidose vial is filled to 6 cc with antigen, the physician may bill Medicare for 6 doses since six 1 cc aliquots may be removed from the vial.
  2. If a 5 cc multidose vial is filled completely, the physician may bill Medicare for 5 doses for this vial.
  3. If a physician removes ½ cc aliquots from a 10 cc multidose vial for a total of 20 doses from one vial, he/she may only bill Medicare for 10 doses. Billing for more than 10 doses would mean that Medicare is overpaying for the PE of making the vial.
  4. If a physician prepares two 10 cc multidose vials, he/she may bill Medicare for 20 doses. However, he/she may remove aliquots of any amount from those vials. For example, the physician may remove ½ aliquots from one vial and 1 cc aliquots from the other vial but may bill no more than a total of 20 doses.
  5. If a physician prepares a 20 cc multidose vial, he/she may bill Medicare for 20 doses, since the PE is calculated based on the physician’s removing 1 cc aliquots from a vial. If a physician removes 2 cc aliquots from this vial, thus getting only 10 doses, he/she may nonetheless bill Medicare for 20 doses because the PE for 20 doses reflects the actual PE of preparing the vial.
  6. If a physician prepares a 5 cc multidose vial, he/she may bill Medicare for 5 doses, based on the way that the PE component is calculated. However, if the physician removes ten ½ cc aliquots from the vial, he/she may still bill only 5 doses because the PE of preparing the vial is the same, without regard to the number of additional doses that are removed from the vial.

Payment may be made for a reasonable supply of antigens that have been prepared for a particular patient if: (1) the antigens are prepared by a physician who is a Doctor of Medicine or osteopathy, and (2) the physician who prepared the antigens has examined the patient and has determined a plan of treatment and a dosage regimen. Antigens must be administered in accordance with the plan of treatment and by a Doctor of Medicine or osteopathy or by a properly instructed person (who could be the patient) under the supervision of the doctor. The associations of allergists that CMS consulted advised that a reasonable supply of antigens is considered to be not more than a 12-month supply of antigens that has been prepared for a particular patient at any one time. The purpose of the reasonable supply limitation is to assure that the antigens retain their potency and effectiveness over the period in which they are to be administered to the patient.

Allergy Shots and Visit Services on the Same Day

Visits should not be billed with allergy injection services 95115 or 95117 unless the visit represents another separately identifiable service.

Claims for maintenance allergy immunotherapy require the EJ modifier.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(24 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
H10.10 Acute atopic conjunctivitis, unspecified eye
H10.11 Acute atopic conjunctivitis, right eye
H10.12 Acute atopic conjunctivitis, left eye
H10.13 Acute atopic conjunctivitis, bilateral
H10.45 Other chronic allergic conjunctivitis
J30.1 Allergic rhinitis due to pollen
J30.2 Other seasonal allergic rhinitis
J30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander
J30.89 Other allergic rhinitis
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description

Please accept the License to see the codes.

N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2 Opens in a new window
Related National Coverage Documents
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Archived Date Status View the document version
01/31/2025 N/A N/A You are here

Keywords

N/A