Dose Counts Matter When Billing 95165

June 1st, 2009

Is your practice billing the number of services for Allergy Immunotherapy CPT® code 95165 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) correctly? The Comprehensive Error Rate Testing (CERT) Payment Safeguard contractor, AdvanceMed, seems to think not, and has put Medicare contractors on the alert.

Report CPT® code 95165 for preparation of multidose vials of non-venom antigens in addition to the appropriate injection code(s).

When reporting 95165, however, be careful how you count doses. According to the Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sect. 200.B.7, “a physician’s removing 10 1 cc aliquot doses [from a 10 cc vial] captures the entire PE [practice expense] component for the service.”

The practice expense payable for the preparation of a vial remains the same regardless of the size or number of aliquots removed from it. Report CPT® 95165 for no more than the total number of doses contained in the vial. Reporting the correct number of doses ensures proper payment.

For example, if a physician prepares a 10 cc multidose vial and removes ½ cc aliquots for a total of 20 doses, the most you can bill Medicare for is 10 doses.

Likewise, if a physician prepares a 20 cc multidose vial and removes 2 cc aliquots for a total of 10 doses, you should bill Medicare for 20 doses. Reporting only 10 doses would result in an underpayment to the practice.


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8 Responses to Dose Counts Matter When Billing 95165

  1. Sheila Sylvan Says:

    To clarify the service, CMS would be advised to work with the AMA to change the descriptor of the code to specify number of CCs, rather than specify number of doses, or this confusion will undoubtedly continue.

    Also, the question on the Test Yourself is awkwardly worded — it appears to state that twenty and one-half ccs were removed from a 10 cc vial, which is physically impossible, rather than the likely intended 20 times 1/2 cc doses.

  2. Janine Margiotta Says:

    I agree, and regarding the test question.

  3. Shannon Says:

    Does the 1cc “aliquot” include diluent? ie. If you mix .2cc of each antigen and add appropriate amount of diluent to make a total volume of 5cc. Would you bill 5cc or the actual amount of concentrate included?

  4. karin messerschmidt Says:

    It seems that Medicare is only allowing 10units per line for 95165. If the doctor is billing 40 allergy preparations how do you bill this. I tried putting 40 in the units box and the claim rejected. I then tried putting 4 lines each with 10 in the unit box and used modifier 51 for multiple procedure. This failed as well. What is the correct way to bill this?

  5. mimilemon80 Says:

    I’ve seen where the physician is billing 150 doses. So confused. help?

  6. Katie R. Says:

    The confusion will remain until CPT changes the description of the code to reflect 1cc=1dose.
    in my search I found this:
    Effective January 1, 2001, for CPT code 95165, a dose is now defined as a one-(1) cc aliquot from a single multidose vial.
    If this is the case then CPT needs to jump on the train and catch up the code and allow for this wording. The confusion would stop.

  7. Tammy Says:

    Per Medicare guidelines, they will only pay up to 30 units at a time.

  8. Natalie Says:

    Where can I find these guidelines that state 30 units? I’ve searched everywhere and it only says 10 units. Also, is this 30 units per day or 30 units per month?

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