Allergy Immunotherapy Coding Guidelines (CMS) Effective: 01/01/2006November 26th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Immunotherapy (Allergy Shots) is a medical treatment to used to treat and prevent reactions or desensitize the immune system to specific allergens that trigger allergy symptoms. Payers have specific coverage guidance and rules for reporting injections, the specific type of antigen(s) provided and how they should be reported.
Below are the coding guidelines from CMS' LCD Allergy Immunotherapy (A17833)
1. The guidelines of the Correct Coding Initiative (CCI) supersede all coding instructions in this LCD. For a complete listing of CCI coding combinations, refer to CMS' website, http://www.cms.hhs.gov/NationalCorrectCodInitEd
2. The diagnosis code(s) must best describe the patient's condition for which the service was performed.
3. Billed services for which the provider expects a medical necessity denial should have either the GA (with signed ABN) or GZ (without signed ABN) modifier attached to the code. If the service is statutorily non-covered or without benefit category, use the GY modifier instead.
4. Always use the component codes (95115, 95117, 95144-95170) when reporting allergy immunotherapy services to Medicare. Report the injection only codes (95115 and 95117) and/or the codes representing antigens and their preparation (95144-95170). Do not use the complete service codes (95120-95134)!
5. Use CPT component procedure codes 95115 (single injection) and 95117 (multiple injections) to report the allergy injection alone, without the provision of the antigen.
6. Use CPT component procedure codes 95144-95170 (provision of antigens) to report the antigen/antigen preparation service when this is the only service rendered by the physician.
7. Use CPT procedure codes 95115/95117 and the appropriate CPT procedure code from the range 95145-95170 when reporting both the injection and the antigen/antigen preparation service (complete service). These instructions also apply to allergists who provide both services through the use of treatment boards.
8. The provision of antigens must be coded based on the specific type of antigen provided:
CPT code 95144 is used to report regular antigens, other than
CPT procedure code 95165 is used to report multiple dose vials of non-venom antigens. Effective January 1, 2001, for CPT code 95165, a dose is now defined as a one (1) cc aliquot from a single
CPT procedure codes 95145-95149 and 95170 are used to report stinging insect venoms. Venom doses are prepared in separate vials and not mixed together -except in the case of the three vespid mix (white and yellow hornets and yellow jackets). Use the code within the range that is appropriate to the number of venoms provided. If a code for more than one venom is reported, some amount of each of the venoms must be provided. Use of a code below the venom treatment number for the particular patient should occur only for the purpose of "catching up" (see coding guideline # 7).
The antigen codes (95144-95170) are considered single-dose codes. To report these codes, specify the number of doses provided.
If a patient’s doses are adjusted (e.g., due to reaction), and the antigen provided is actually more or fewer doses than originally anticipated, make no change in the number of doses billed. Report the number of doses actually anticipated at the time of the antigen preparation. These instructions apply to both venom and non-venom antigen codes.
9. The physician should make no change in the number of doses for which he/she bills even if the patient’s doses are adjusted. The number of doses anticipated at the time of the antigen preparation is the number of doses that should be billed. If the patient actually receives more doses than originally planned (due to a decrease in the amount of antigen administered during treatment) or fewer doses (due to an increase in the amount of antigen administered), no change should be made in the billing.
10. When a venom regimen requires that antigens
11. A visit to an allergist, which yields a diagnosis of specific allergy sensitivity but does not include immunotherapy, should be coded according to the level of care rendered.
12. Evaluation and management (E&M) codes billed with allergy testing or allergy immunotherapy are appropriate only if a significant, separately identifiable service is administered. When appropriate, use modifier -25 with the E&M code to indicate it as a separately identifiable service.
13. Use CPT procedure code 95180 (rapid desensitization) when sensitivity to a drug has been established and treatment with the drug is essential. This procedure will also require frequent monitoring and skin testing. The number of hours involved in desensitization must be reported in the unit’s field.
14. CPT procedure codes 95115 and 95117 are payable in the office (11) and independent clinic (49)*.
CPT procedure codes 95145-95170 are payable in the office (11), outpatient department (22) and, independent clinic (49)*. These codes are also payable in a skilled nursing facility (31), but only if the physician is present.
CPT procedure code 95144 is payable in the office (11) and independent clinic (49)*.
CPT procedure code 95180 is payable in the office (11), inpatient hospital (21), outpatient hospital (22), emergency hospital (23) and independent clinic (49)*
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