CurrentPremera BluecrossPolicy N/A

Allergen immunotherapy (CPT 95165) unit limits

Defines unit limits and billing guidance for professional reporting of allergen immunotherapy (CPT 95165) for Premera Blue Cross and affiliated lines of business; applies to professional claims (CMS-1500/837P) and all listed Premera products.

Policy Summary

PayerPremera Bluecross

PolicyAllergen immunotherapy (CPT 95165) unit limits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateDec 17, 2018

Key ActionIf separate and distinct services unrelated to the allergen immunotherapy are provided, bill an appropriate E&M with modifier 25 only if documentation supports a significant, separately billable service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

150maximum daily units per member per provider

250maximum units per member per rolling 12-month period

professionalclaim form type

Payment Integrity Oversight Committeepolicy owner

Coverage Criteria

Coverage criteria for CPT 95165

Coverage for professional services preparing/providing antigens is allowed subject to unit limits and documentation requirements.

ALL of the following

Permitted code: CPT 95165 is recognized for reporting preparation and provision of antigens; this code reports the physician's preparation of antigen(s), concentration and volume, and provision of the antigen extract, and does NOT include the actual administration of the allergen therapy.
Unit reporting rule: The unit value submitted should reflect the actual number of doses prospectively planned to be administered for a patient’s course of treatment when the antigen is initially prepared; if doses are later adjusted or diluted and the antigen provided is more or less than originally anticipated, the number of doses billed should not be changed.
Daily unit limit: Maximum 150 units per day per member per provider.

Policy Summary

PayerPremera Bluecross

PolicyAllergen immunotherapy (CPT 95165) unit limits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateDec 17, 2018

SourceLink

On This Page

Coding and Quantity Limits

Allergen immunotherapy preparationCPTCovered

95165

Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple dose antigens (specify the number of doses).

inv-03: Maximum daily units per member per provider

Maximum daily limit150 units per day, per member, per provider

ScopeApplies to professional claims for Premera Blue Cross and affiliated lines of business and products

Unit reporting ruleUnit value submitted should reflect the actual number of doses prospectively planned when antigen is initially prepared

inv-04: Maximum units per member per rolling 12-month period (all providers combined)

Maximum rolling 12-month limit250 units per member per rolling 12-month period (includes all provider submissions)

ApplicabilityLimit is cumulative across all providers for the member

Claim typeApplies to professional claims (CMS-1500/837P)

Provider Billing and Documentation Actions

Billing Rule

Bill E&M with modifier 25 only when documentation supports a separate, substantial service

If additional separate and distinct services unrelated to the allergen immunotherapy are rendered at the same time as the preparation of the allergen immunotherapy, an appropriate E&M office visit code with modifier 25 may be submitted only when the medical record documentation supports the E&M service as a significant, separately billable service unrelated to the procedure. Additional separate and distinct services must be substantial and fully documented in the patient's medical record.

Submit E&M with modifier 25 only when documentation demonstrates a significant, separately identifiable service unrelated to the immunotherapy preparation.
Ensure the medical record contains full documentation of the separate service to justify payment.

Definitions

inv-06: the repeated administration of specific allergens to a patient with IgE-mediated conditions to provide protection against allergy symptoms and inflammatory reactions associated with natural exposure to these allergens.

DefinitionAllergen immunotherapy: the repeated administration of specific allergens to a patient with IgE-mediated conditions to provide protection against allergy symptoms and inflammatory reactions associated with natural exposure to these allergens.

PurposeProvides protection against allergy symptoms and inflammatory reactions associated with natural exposure to specific allergens

Context of useUsed to describe the therapy for which CPT 95165 reports preparation and provision of antigen(s)

inv-07: the amount of antigen administered in a single injection from a multiple dose vial or drawn from a treatment board in one syringe.

DefinitionDose: the amount of antigen administered in a single injection from a multiple dose vial or drawn from a treatment board in one syringe.

Relation to CPT 95165Unit value reported for CPT 95165 should reflect the number of doses prospectively planned when antigen is initially prepared

Billing noteIf doses are adjusted after preparation, providers should not change the number of doses initially billed