Billing CPT Code 95165 Correctly

Allergy Immunotherapy - Billing CPT Code 95165 Correctly

CMS instructs providers to bill CPT code 95165 for Medicare beneficiaries. The Comprehensive Error Rate Testing (CERT) Payment Safeguard contractor, AdvanceMed, has highlighted an area of concern to NAS and its provider community. The concern specifically is that the number of services being billed for CPT code 95165 is, in some cases, incorrect.

"7. Code 95165 Doses. - Code 95165 represents preparation of vials of non-venom antigens. As in the case of venoms, some non-venom antigens cannot be mixed together, i.e., they must be prepared in separate vials. An example of this is mold and pollen. Therefore, some patients will be injected at one time from one vial – containing in one mixture all of the appropriate antigens – while other patients will be injected at one time from more than one vial. In establishing the practice expense (PE) component for mixing a multidose vial of antigens, we observed that the most common practice was to prepare a 10 cc vial; we also observed that the most common use was to remove aliquots with a volume of 1 cc. Our 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 practice expenses payable for the preparation of a 10cc 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 practice expense component attributable to this service. (Note that this code does not include the injection of antigen(s); injection of antigen(s) is separately billable.)

When a multidose vial contains less than 10cc, 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 10cc in the vial.

If it is medically necessary, physicians may bill Medicare for preparation of more than one multidose vial.