Policy Statement
The units billed for CPT code 95165 should reflect the actual number of doses the provider plans to administer as the patient’s course of treatment when the antigen is initially prepared. Depending on the patient treatment plan, preparation of the antigen may be billed more than once per year but limited to once per course of treatment. Regardless of the number of treatment plan(s) in any given year, the units billed are still subject to the unit maximum below per 365 days. Units should be billed on the preparation date and not split over subsequent days. If the patient’s doses are adjusted and the antigen provided is more or fewer doses than originally anticipated, there should be no change in the number of doses for which the provider already anticipated billing.
The following limits will be applied to CPT code 95165:
- 150 units per 365 days/per member maximum
Individuals must be re-evaluated every 6 to 12 months while receiving allergy immunotherapy for all the following:
- To determine efficacy; and
- To determine whether adjustments in the dosing schedule or allergen content are necessary; and
- To ensure compliance; and
- To monitor for the two types of adverse reactions: local (i.e., redness and swelling at the injection site) and systemic (i.e., sneezing, nasal congestion, or hives).
The length of time that a patient would have ongoing immunotherapy should be individualized based on the patient’s clinical response, disease severity and immunotherapy reaction history. The duration of the course of treatment is determined upon each patient. Records must be submitted if requested to verify this. Immunotherapy includes professional services necessary for the preparation and provision of the allergen immunotherapy.
If additional separate and distinct services are rendered at the same time as the preparation of the allergen immunotherapy, then an appropriate evaluation and management (E&M) office visit code with modifier 25 may be submitted if documentation supports that separate and distinct services were rendered.
References
Cross References
- Mod 103 - Modifier 25; Significant, Separately Identifiable Service
