CPT CODES – 95115, 95117, 95165, 95180 and Allergen Immunotherapy – ICD 10 (2023)

Procedure code and description


95165 Professional Services Supervision Provisions Antig

95115 – Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection

95117 – Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections

ALLERGY TESTING AND ALLERGEN IMMUNOTHERAPY

In billing for allergy testing and allergen immunotherapy, providers are to use the most appropriate and inclusive Procedure code that describes the services provided. Unless otherwise listed, Louisiana Medicaid uses the definitions and criteria found in the Current Procedural Terminology Manual (Procedure ).

Definitions

Allergy testing describes the performance and evaluation of selective cutaneous and mucous membrane tests in correlation with the history, physical examination, and other observations of the recipient. The number of tests performed should be judicious and dependent upon the history, physical findings, and clinical judgment of the provider. All patients should not necessarily receive the same tests or the same number of tests.

Immunotherapy is the parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage which is maintained as maintenance therapy. The method of administration and the dosage administered should be included in the recipient’s record. Indications for immunotherapy are determined by appropriate diagnostic procedures and clinical judgment. The procedure codes used for allergen immunotherapy include the necessary professional services associated with this therapy which includes the monitoring of the injection site and observation of the patient for adverse reactions.

Office visit codes may be billed in addition to immunotherapy only if other significant identifiable services are provided at that time.



Allergen Immunotherapy


Coding

1. 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)!

2. Use CPT component procedure codes 95115 (single injection) and 95117 (multiple injections) to report the allergy injection alone, without the provision of the antigen.

3. 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.

4. 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.

5. 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 stinging insect. Use this code to report single dose vials. Use this code only when the allergist actually prepares the extract. Code 95144 (single dose vials of antigen) should be reported only if the physician providing the antigen is providing it to be injected by someone other than himself/herself. If this code is mistakenly reported in conjunction with an injection (95115 or 95117), payment will be made under code 95165.
· 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 multidose vial. When billing code 95165, providers should report the number of
units representing the number of 1 cc doses being prepared. A maximum of 10 doses per vial is allowed for Medicare billing, even if more than ten preparations are obtained from the vial. In cases where a multidose vial is diluted, Medicare should not be billed for diluted preparations in excess of the 10 doses per vial allowed under code 95165.

· 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.

6. 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.

7. When a venom regimen requires that antigens be mixed from more than one vial for administration and, due to a dose adjustment of one of the antigens, one vial is depleted before the other, the physician may bill for “catch-up” doses of the short antigen. This must be done in a manner that synchronizes the preparation back to the highest venom code possible in the shortest amount of time. To catch up, the physician would bill only the amount of the depleted vial needed to catch-up with the other vials. This will permit the physician to get back to preparing the full number of venoms at one time and billing the doses of the “cheaper” higher venom codes. Use of a code below the venom treatment number for the particular patient should occur only for the purpose of “catching up”

8. 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.

9. 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.

10. Allergy Shots and Visit Services on Same Day



EXAMPLES:

(1) If a 10cc multidose vial is filled to 6cc with antigen, the physician may bill Medicare for 6 doses since six 1cc aliquots may be removed from the vial.

(2) If a 5cc multidose vial is filled completely, the physician may bill Medicare for 5 doses for this vial.

(3) If a physician removes ½ cc aliquots from a 10cc multidose vial for a total of 20 doses from one vial, he/she may only bill Medicare for 10 doses. Billing for more than 10 doses would mean that Medicare is overpaying for the practice expense of making the vial.

(4) If a physician prepares two 10cc multidose vials, he/she may bill Medicare for 20 doses. However, he/she may remove aliquots of any amount from those vials. For example, the physician may remove ½ aliquots from one vial, and 1cc aliquots from the other vial, but may bill no more than a total of 20 doses.

(5) If a physician prepares a 20cc multidose vial, he/she may bill Medicare for 20 doses, since the practice expense is calculated based on the physician’s removing 1cc aliquots from a vial. If a physician removes 2cc aliquots from this vial, thus getting only 10 doses, he/she may nonetheless bill Medicare for 20 doses because the PE for 20 doses reflects the actual practice expense of preparing the vial.

(6) If a physician prepares a 5cc multidose vial, he may bill Medicare for 5 doses, based on the way that the practice expense component is calculated. However, if the physician removes ten ½ cc aliquots from the vial, he/she may still bill only 5 doses because the practice expense of preparing the vial is the same, without regard to the number of additional doses that are removed from the vial.



DESCRIPTION


Allergy testing, evaluations, and immunotherapy are eligible for coverage according to the schedule of covered services in plan documents. Testing or treatment methods not considered as standard medical procedures are not eligible for coverage.


CODING INFORMATION


ICD-10 Codes that may support medical necessity:


D69.0 Allergic purpura


H10.401 – H10.409 Unspecified chronic conjunctivitis
H10.421 – H10.429 Simple chronic conjunctivitis
H10.44 Vernal conjunctivitis
H16.261 – H16.269 Vernal keratoconjunctivitis, with limbar and corneal
H10.411 – H10.419 Chronic giant papillary conjunctivitis
H10.45 Other chronic allergic conjunctivitis
H10.9 Unspecified conjunctivitis
J30.0 – J30.9 Vasomotor and allergic rhinitis
J31.0 – J31.2 Chronic rhinitis, nasopharyngitis and pharyngitis
J32.0 – J32.9 Chronic sinusitis
J33.0 – J33.9 Nasal polyp
J45.20 – J45.998 Asthma
K52.2 Allergic and dietetic gastroenteritis and colitis
K52.89 Other specified noninfective gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis, unspecified
L20.0 – L20.9 Atopic dermatitis
L22 Diaper dermatitis
L23.0 – L23.9 Allergic contact dermatitis
L24.0 – L24.9 Irritant contact dermatitis
L25.0 – L25.9 Unspecified contact dermatitis
L27.0 – L27.9 Dermatitis due to substances taken internally
L29.8 Other pruritus
L29.9 Pruritus, unspecified
L30.0 – L30.9 Other and unspecified dermatitis
L50.0 Allergic urticaria
L50.1 Idiopathic urticaria
L50.6 Contact urticaria
L50.8 Other urticaria
L50.9 Urticaria, unspecified
L56.4 Polymorphous light eruption
T50.905A-T50.905S Adverse effect of unspecified drugs, medicaments and biological substances
T50.995A-T50.905S Adverse effect of other drugs, medicaments and biological substances
T78.00xA-T78.1xxS Anaphylactic reaction due to food


Limitations:

Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

CPT/HCPCS Codes


Group 1 Paragraph: N/A


Group 1 Codes:


95115 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION


95117 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 OR MORE INJECTIONS


95144 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY, SINGLE DOSE VIAL(S) (SPECIFY NUMBER OF VIALS)


95145 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); SINGLE STINGING INSECT VENOM


95146 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); 2 SINGLE STINGING INSECT VENOMS


95147 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); 3 SINGLE STINGING INSECT VENOMS


95148 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); 4 SINGLE STINGING INSECT VENOMS


95149 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); 5 SINGLE STINGING INSECT VENOMS


95165 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY; SINGLE OR MULTIPLE ANTIGENS (SPECIFY NUMBER OF DOSES)


95170 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY; WHOLE BODY EXTRACT OF BITING INSECT OR OTHER ARTHROPOD (SPECIFY NUMBER OF DOSES)


95180 RAPID DESENSITIZATION PROCEDURE, EACH HOUR (EG, INSULIN, PENICILLIN, EQUINE SERUM)

Allergen Immunotherapy (Medicare excerpts) Billing Guidelines:

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 multidose vial. When billing code 95165, providers should report the number of units representing the number of 1 cc doses being prepared. A maximum of 10 doses per vial is allowed for Medicare billing, even if more than ten preparations are obtained from the vial. In cases where a multidose vial is diluted, Medicare should not be billed for diluted preparations in excess of the 10 doses per vial allowed under code 95165.

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.”

When a venom regimen requires that antigens be mixed from more than one vial for administration and, due to a dose adjustment of one of the antigens, one vial is depleted before the other, the physician may bill for “catch-up” doses of the short antigen. This must be done in a manner that synchronizes the preparation back to the highest venom code possible in the shortest amount of time. To catch up, the physician would bill only the amount of the depleted vial needed to catch-up with the other vials. This will permit the physician to get back to preparing the full number of venoms at one time and billing the doses of the “cheaper” higher venom codes. Use of a code below the venom treatment number for the particular patient should occur only for the purpose of “catching up.”

(Video) Allergen Immunotherapy Coding Overview — Medical Coding Tips

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.

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.

Allergy Shots and Visit Services on Same Day

Effective for services provided on or after January 1, 1995, visits may not be paid with allergy injection services 95115 through 95199 unless the visit represents another separately identifiable service. Modifier code -25 is used with the visit code to report the patient’s condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided. Coding Guidelines:

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)! Use CPT procedure codes 95115 (single injection) and 95117 (multiple injections) to report the allergy injection alone, without the provision of the antigen.

Use CPT procedure codes 95144-95170 (provision of antigens) to report the antigen/antigen preparation service when this is the only service rendered by the physician. 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.

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 stinging insect. Use this code to report single dose vials. Use this code only when the allergist actually prepares the extract. Code 95144 (single dose vials of antigen) should be reported only if the physician providing the antigen is providing it to be injected by someone other than himself/herself. If this code is mistakenly reported in conjunction with an injection (95115 or 95117), payment will be made under code 95165.

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 field. 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.

For place of service the following is covered:

CPT procedure codes 95115, 95117 and 95144 are payable only in an office setting (11). CPT procedure codes 95145-95170 are payable in the office (11) and in a hospital outpatient department (22). These codes are also payable in a skilled nursing facility (31), but only if the physician is present. CPT procedure codes 95060, 95065, 95180 are payable in office (11) and hospital settings (21, 22, 23).

Indications:


Indications for immunotherapy are determined by appropriate diagnostic procedures coordinated with clinical judgment and knowledge of the natural history of allergic diseases. The following indications are considered medically reasonable and necessary for allergy immunotherapy:




Controlled studies have shown that allergen immunotherapy is effective for patients with Allergic rhinitis, Allergic conjunctivitis, Allergic asthma, and Stinging insect hypersensitivity.




Allergen-induced asthma is an indication for immunotherapy along the guidelines for allergic rhinitis when there is a poor response to environmental control or pharmacologic treatment. Allergen immunotherapy in asthmatic patients should not be initiated unless the patient’s asthma is stable. Patients with severe or uncontrolled asthma are at increased risk for systemic reactions to immunotherapy injections.


The necessity of allergen immunotherapy depends on the Degree to which symptoms can be reduced by medications, Ability of the patient to tolerate possible side effects of the medication, Amount, type and cost of the medications required to control symptoms, Significant exposure to an allergen in which there is a significant level of sensitivity and the pattern of symptoms conform to the pattern of exposure, and Whether conservative therapies (including avoidance) have failed to control the symptoms, or avoidance of the relevant antigen (e.g., dust mites, pollen, and mold) is impractical.




Animal dander sensitivity (epidermal) may respond to immunotherapy. While removal of the offending allergen is recommended, this is often not possible or there may be occupational or other sources of exposure. Antihistamines are used first before immunotherapy but a trial of immunotherapy may be warranted if the antihistamines do not relieve symptoms.


Aeroallergen immunotherapy is indicated for patients with allergic rhinitis due to:
Seasonal pollinosis caused by trees, grasses and weeds.


The treatment of mold-induced rhinitis.


Perennials such as cat and dog dander, dust mite and cockroach.


Standardized dust mite extracts appear effective for immunotherapy. Other environmental allergens (e.g., kapok, jute, feathers, and unstandardized house dust extracts) are of questionable value in immunotherapy, however, and generally should not be used.


Venom immunotherapy is indicated for patients who have a severe systemic anaphylactic reaction after an insect sting and a positive skin test or other documented IgE sensitivity to specific insect venom.


Patients with delayed systemic reactions, with symptoms of anaphylaxis or serum sickness and with a positive skin test or presence of venom specific IgE by in vitro testing are also recommended for treatment.


Rapid desensitization is indicated in cases of allergy to insulin, penicillin and horse serum, as well as sulfonamides, cephalosporins and other commonly used drugs (e.g. aspirin). In patients with a positive history of reaction and with documented skin test reactivity, every effort should be made to avoid the use of these substances. When circumstances require the use of one of these substances, the patient will have to be desensitized. Desensitization may need to be repeated if future circumstances require an additional course of the offending allergen. Full-dose therapy should be initiated immediately after reactions (treated and controlled), requiring strict physician monitoring in a setting with continuous monitoring of vital signs and cardio-respiratory status. In most cases, this can be performed in a physician’s office if a physician trained to treat anaphylaxis is physically present for the entire duration. In cases where the initial reaction was severe, desensitization should be performed in the ambulatory care department of a hospital.


Limitations:


The following allergy immunotherapy are considered investigational and experimental, therefore, are not medically necessary. The effectiveness also has not been established, therefore, these indications will not be covered:
Angioedema.


Food hypersensitivity/allergy.


Intrinsic (non-allergic) asthma.


Migraine headaches.


Non-allergic vasomotor rhinitis.


With the following services, allergy immunotherapy services are considered investigational and experimental, therefore, are not medically necessary. The effectiveness also has not been established, therefore, these indications will not be covered:
Therapy with allergoids or adjuvants.


Therapy via other administration:
Oral or sublingual food immunotherapy*,


Epicutaneous immunotherapy,


Intralymphatic immunotherapy,


Intranasal immunotherapy, or


Sublingual immunotherapy.


Desensitization with commercially available extracts of poison ivy, poison oak, or poison sumac.


Desensitization for hymenoptera sensitivity using whole body extracts, with the exception of fire ant extracts**.


Desensitization with bacterial vaccine (BAC: bacterial, antigen complex, streptococcus vaccine, staphylo-strepto vaccine, serobacterin, staphylococcus phage lysate).


Food allergenic extracts immunotherapy.


Intracutaneous desensitization (Rinkel Injection Therapy, RIT).


Intracutaneous titration.


Neutralization therapy (intradermal and subcutaneous).


Repository emulsion therapy.


Sublingual desensitization***.


Sublingual provocative therapy***.


Urine auto-injection (autogenous urine immunotherapy).


Allergen immunotherapy for the management of skin and mucous membrane disease such as atopic dermatitis, chronic urticaria, and Candida vulvovaginitis.


Postmortem examination for IgE antibodies to identify allergens responsible for lethal anaphylaxis (post mortem work is not-covered by Medicare).


Patients who are mentally or physically unable to communicate clearly with the allergist and those with a history of noncompliance are not good candidates for allergy immunotherapy. If a patient cannot communicate clearly with the physician; it will be difficult for the patient to report signs and symptoms, especially early symptoms, suggestive of systemic reactions.


*Several clinical trials with oral and sublingual immunotherapy demonstrate an increased tolerance to oral food challenge in subjects with food hypersensitivity while receiving therapy. Oral and sublingual food immunotherapy is investigational. At present, the only treatment for food hypersensitivity is avoidance.


**Immunotherapy with whole-body extracts of biting insects or other arthropod is covered only for fire ant extracts.



***Sublingual immunotherapy (SLIT) involves the use of FDA approved allergenic extracts administered orally. In early 2014, the FDA approved oral administration of 3 allergenic extracts, two for grasses and one for ragweed. These extracts are not approved by the FDA for anyone over the age of 65 years. Medicare does not cover sublingual immunotherapy. Effective October 31, 1988, sublingual intracutaneous and subcutaneous provocative and neutralization testing and neutralization therapy for food allergies are excluded from Medicare coverage because available evidence does not show that these tests and therapies are effective. (CMS Pub 100-03 Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, Part 2, Section 110.11 – Food Allergy Testing and Treatment).

ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

H10.411 Chronic giant papillary conjunctivitis, right eye

H10.412 Chronic giant papillary conjunctivitis, left eye

H10.413 Chronic giant papillary conjunctivitis, bilateral

H10.45 Other chronic allergic conjunctivitis

J30.0 Vasomotor rhinitis

J30.1 Allergic rhinitis due to pollen

J30.2 Other seasonal allergic rhinitis

J30.5 Allergic rhinitis due to food

J30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander

J30.89 Other allergic rhinitis

J30.9 Allergic rhinitis, unspecified

J45.20 Mild intermittent asthma, uncomplicated

J45.21 Mild intermittent asthma with (acute) exacerbation

J45.22 Mild intermittent asthma with status asthmaticus

J45.30 Mild persistent asthma, uncomplicated

J45.31 Mild persistent asthma with (acute) exacerbation

J45.32 Mild persistent asthma with status asthmaticus

J45.40 Moderate persistent asthma, uncomplicated

J45.41 Moderate persistent asthma with (acute) exacerbation

J45.42 Moderate persistent asthma with status asthmaticus

J45.50 Severe persistent asthma, uncomplicated

J45.51 Severe persistent asthma with (acute) exacerbation

J45.52 Severe persistent asthma with status asthmaticus

(Video) Billing and Coding (Gross)

J45.909 Unspecified asthma, uncomplicated

J45.998 Other asthma

J82 Pulmonary eosinophilia, not elsewhere classified

T63.421A Toxic effect of venom of ants, accidental (unintentional), initial encounter

T63.421D Toxic effect of venom of ants, accidental (unintentional), subsequent encounter

T63.421S Toxic effect of venom of ants, accidental (unintentional), sequela

T63.422A Toxic effect of venom of ants, intentional self-harm, initial encounter

T63.422D Toxic effect of venom of ants, intentional self-harm, subsequent encounter

T63.422S Toxic effect of venom of ants, intentional self-harm, sequela

T63.423A Toxic effect of venom of ants, assault, initial encounter

T63.423D Toxic effect of venom of ants, assault, subsequent encounter

T63.423S Toxic effect of venom of ants, assault, sequela

T63.424A Toxic effect of venom of ants, undetermined, initial encounter

T63.424D Toxic effect of venom of ants, undetermined, subsequent encounter

T63.424S Toxic effect of venom of ants, undetermined, sequela

T63.441A Toxic effect of venom of bees, accidental (unintentional), initial encounter

T63.441D Toxic effect of venom of bees, accidental (unintentional), subsequent encounter

T63.441S Toxic effect of venom of bees, accidental (unintentional), sequela

T63.442A Toxic effect of venom of bees, intentional self-harm, initial encounter

T63.442D Toxic effect of venom of bees, intentional self-harm, subsequent encounter

T63.442S Toxic effect of venom of bees, intentional self-harm, sequela

T63.443A Toxic effect of venom of bees, assault, initial encounter

T63.443D Toxic effect of venom of bees, assault, subsequent encounter

T63.443S Toxic effect of venom of bees, assault, sequela

T63.444A Toxic effect of venom of bees, undetermined, initial encounter

T63.444D Toxic effect of venom of bees, undetermined, subsequent encounter

T63.444S Toxic effect of venom of bees, undetermined, sequela

T63.451A Toxic effect of venom of hornets, accidental (unintentional), initial encounter

T63.451D Toxic effect of venom of hornets, accidental (unintentional), subsequent encounter

T63.451S Toxic effect of venom of hornets, accidental (unintentional), sequela

T63.452A Toxic effect of venom of hornets, intentional self-harm, initial encounter

T63.452D Toxic effect of venom of hornets, intentional self-harm, subsequent encounter

T63.452S Toxic effect of venom of hornets, intentional self-harm, sequela

T63.453A Toxic effect of venom of hornets, assault, initial encounter

T63.453D Toxic effect of venom of hornets, assault, subsequent encounter

T63.453S Toxic effect of venom of hornets, assault, sequela

T63.454A Toxic effect of venom of hornets, undetermined, initial encounter

T63.454D Toxic effect of venom of hornets, undetermined, subsequent encounter

T63.454S Toxic effect of venom of hornets, undetermined, sequela

T63.461A Toxic effect of venom of wasps, accidental (unintentional), initial encounter

T63.461D Toxic effect of venom of wasps, accidental (unintentional), subsequent encounter

(Video) Allergy Billing and Coding (Gross)

T63.461S Toxic effect of venom of wasps, accidental (unintentional), sequela

T63.462A Toxic effect of venom of wasps, intentional self-harm, initial encounter

T63.462D Toxic effect of venom of wasps, intentional self-harm, subsequent encounter

T63.462S Toxic effect of venom of wasps, intentional self-harm, sequela

T63.463A Toxic effect of venom of wasps, assault, initial encounter

T63.463D Toxic effect of venom of wasps, assault, subsequent encounter

T63.463S Toxic effect of venom of wasps, assault, sequela

T63.464A Toxic effect of venom of wasps, undetermined, initial encounter

T63.464D Toxic effect of venom of wasps, undetermined, subsequent encounter

T63.464S Toxic effect of venom of wasps, undetermined, sequela

T78.2XXA Anaphylactic shock, unspecified, initial encounter

T78.2XXD Anaphylactic shock, unspecified, subsequent encounter

T78.2XXS Anaphylactic shock, unspecified, sequela

T78.40XA Allergy, unspecified, initial encounter

T78.40XD Allergy, unspecified, subsequent encounter

T78.40XS Allergy, unspecified, sequela

T78.49XA Other allergy, initial encounter

T78.49XD Other allergy, subsequent encounter

T78.49XS Other allergy, sequela

T88.6XXA Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, initial

encounter

T88.6XXD Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, subsequent

encounter

T88.6XXS Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, sequela

Z91.02* Food additives allergy status

Z91.030 Bee allergy status

Z91.038 Other insect allergy status

Z91.048 Other nonmedicinal substance allergy status

Z91.09 Other allergy status, other than to drugs and biological substances

ICD-9-CM Codes that Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage forCPT/HCPCS codes95115, 95117, 95144, 95145, 95146, 95147, 95148,95149, 95165 and 95180:





Covered for:

372.05

Acute atopic conjunctivitis

372.14

Other chronic allergic conjunctivitis

381.00381.06

Acute nonsuppurative (allergic) otitis media

471.0

(Video) Principles of Patient Billing (Gross)

Polyp of nasal cavity

471.8

Other polyp of sinus

473.0473.3

Chronic sinusitis

477.0477.2

Allergic rhinitis

477.8477.9

Allergic rhinitis

493.00

Extrinsic asthma unspecified

493.10493.11

Intrinsic asthma

493.20

Chronic obstructive asthma unspecified

493.90493.91

Asthma unspecified

691.8

Other atopic dermatitis and related conditions

692.9

Contact dermatitis and other eczema, unspecified cause

693.1

Dermatitis due to food taken internally

989.5

Toxic effect of venom

995.0

Other anaphylactic shock not elsewhere classified

995.21995.23

Unspecified adverse effect of drug, medicinal and biological substance

995.27

Other drug allergy

995.29

Unspecified adverse effect of other drug, medicinal and biological substance

995.3

Allergy unspecified not elsewhere classified

V14.0V14.3

Personal history of allergy to medicinal agents

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses that DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

(Video) Billing and Coding (Gross)

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

FAQs

What does CPT code 95115 mean? ›

Use CPT component procedure codes 95115 (single injection) and 95117 (multiple injections) to report the allergy injection alone, without the provision of the antigen.

What is the CPT code for immunotherapy? ›

Use CPT procedure codes 95115 or 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.

What is the ICD 10 code for allergy shot? ›

Similarly, for the allergy shot encounter – ICD-10-CM guidelines state that Z51. 6 (Encounter for desensitization to allergens) may be used as the primary diagnosis code for the shot visit (eg, 95115, 95117, 95165) and the J code as a secondary diagnosis code.

Does 95117 need a modifier? ›

You may report 99212 and 95117, according to Medicare rules. According to the Correct Coding Initiative, a modifier is not needed to code both codes.

What does CPT code 95165 mean? ›

Per local coverage determination (LCD) L34597, code 95165 is for reporting multi-dose vials of non-venom antigens. Effective Jan. 1, 2001, a dose is defined as 1 cc aliquot from a single multi-dose vial. Providers should report the number of units representing the number of 1 cc doses prepared.

How many units can you bill for 95165? ›

CPT Code 95165

If a multi-dose vial contains less than 10cc, bill the number of 1 cc aliquots that may be removed from the vial up to a maximum of 10 doses per multi-dose vial. If medically necessary, physicians may bill for preparation of more than one multi-dose vial.

Can 96372 and 95117 be billed together? ›

Per NCCI, 96372 does bundle to 95117, but a modifier is allowed.

What is the CPT code for allergy shots? ›

Use CPT procedure codes 95115 (single injection) and 95117 (multiple injections) to report the allergy injection alone, without the provision of the antigen.

What is the difference between CPT code 95115 and 95120? ›

Codes 95115-95117 describes the professional service for the injection of the antigen but does not include the supply of the antigen. 2. Codes 95120-95134 describes complete service codes representing the combined preparation and supply of antigen for allergy immunotherapy in addition to the allergy injection provided.

What is the ICD-10 code for immunotherapy? ›

If infusion for antineoplastic immunotherapy is the only reason for the patient encounter, physicians and hospitals may report ICD-10-CM code “Z51. 12 Encounter for antineoplastic immunotherapy” as the primary diagnosis.

What ICD-10 codes cover allergy testing? ›

ICD-10 code Z01. 82 for Encounter for allergy testing is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .

What is the ICD-10 code for allergies unspecified? ›

ICD-10 code T78. 40 for Allergy, unspecified is a medical classification as listed by WHO under the range - Injury, poisoning and certain other consequences of external causes .

How do I bill CPT 95117? ›

Use code 95115 per encounter for a single injection and 95117 for a single encounter where two or more injections are given. An allergist or other supplier prepares or supervises the preparation of single dose vials of antigens for allergen immunotherapy.

Does Medicare pay for 95165? ›

CMS defines the 95165 code as a 1-cc aliquot from a single multiple dose vial. Diluted doses are not billable according to the CMS definition. If you are mixing a “set” for a Medicare patient, you will charge only for the vial that is designated as the maintenance vial.

What is the Mue for CPT 95165? ›

How many MUE's can be billed in a day?
CodeDescriptionMedicare and Medicaid MUE
95149Venom immunotherapy/5 venoms10
95165Allergen immunotherapy/multi-dose vials30
95170Allergen immunotherapy/whole body extract10
95180Rapid desensitization/each hour6
15 more rows
19 Feb 2018

How often can you bill 95165? ›

A maximum of 10 doses per vial is allowed for Medicare billing, even if more than 10 preparations are obtained from the vial. In cases where a multi-dose vial is diluted, you cannot bill Medicare for diluted preparations more than the 10 doses per vial allowed. To report 95165, designate the number of doses.

Are allergy shots immunotherapy? ›

Allergy shots are regular injections over a period of time — generally around three to five years — to stop or reduce allergy attacks. Allergy shots are a form of treatment called immunotherapy. Each allergy shot contains a tiny amount of the specific substance or substances that trigger your allergic reactions.

Are allergy injections covered by Medicare? ›

Medicare Part B covers most of the cost of allergy shots if they're deemed medically necessary.

What is the CPT code for allergy testing? ›

The Current Procedural Terminology (CPT®) code 95044 as maintained by American Medical Association, is a medical procedural code under the range - Allergy Testing Procedures.

What does allergy immunotherapy do? ›

Immunotherapy is a preventive treatment for allergic reactions to substances such as grass pollens, house dust mites and bee venom. Immunotherapy involves giving gradually increasing doses of the substance, or allergen, to which the person is allergic.

How do you bill a patch test? ›

Photo patch tests (CPT code 95052) consist of applying a patch(s) containing allergenic substance(s) (same antigen/same session) to the skin and exposing the skin to light.

What is CPT code 96372 used for? ›

CPT® code 96372: Injection of drug/substance under skin or into muscle | American Medical Association.

Can CPT code 96372 Be bill with an office visit? ›

If you administer an injection in your office, e.g., naltrexone extended-release (Vivitrol®) or depot antipsychotics, you can bill for the administration of the injection separately from the billing for the visit itself. The CPT code 96372 should be used–Therapeutic, prophylactic, or diagnostic injection.

What is the difference between CPT code 96372 and 90471? ›

90471 is an Immunization administration code. TB TEST IS NOT AN IMMUNIZATION. Furthermore 96372 is for Therapeutic/Diagnostic injection, Subcutaneous or Intramuscular.

How do you file allergy shots? ›

Allergy Shots: Understanding Documentation Guidelines
  1. There should be a prescription, signed and dated by the physician, documenting the specific allergen extract(s) that will be administered;
  2. Protocols for dosing and dose adjustments must be detailed, including schedules for: Escalation, or projected build-up schedule,
10 Oct 2017

What are CPT codes? ›

What is a CPT® code? The Current Procedural Terminology (CPT®) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency.

What is a personal allergy code? ›

What is a PAC? PAC (Personal Allergy Code) is a code given to you by your physician after you get patch tested and receive your list of allergens. You may enter this code into the SkinSAFE app to automatically download your customized database of safe products.

What is allergen desensitization? ›

This treatment allows the immune system to "get used to" (become desensitized to) the allergen. That can relieve symptoms. The goal of allergen-specific immunotherapy is to reduce allergy symptoms in the medium to long term. It takes about three years. Immunotherapy can be used in both children and adults.

What is provision of allergenic extract? ›

allergenic extract an extract of allergenic components from a crude preparation of an allergen, such as weed, grass, or tree pollen, molds, house dust, or animal dander, used for diagnostic skin testing or for immunotherapy for allergy.

How many units can you bill for 95004? ›

If a physician performs 25 percutaneous tests (scratch, puncture, or prick) with allergenic extract, the physician must bill code 95004 and specify 25 in the units field of Form CMS-1500 (paper claims or electronic format).

What is the ICD-10 code for long term use of immunotherapy? ›

Personal history of immunosuppression therapy

Z92. 25 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2023 edition of ICD-10-CM Z92. 25 became effective on October 1, 2022.

What is the ICD-10 code Z79 899? ›

ICD-10 code Z79. 899 for Other long term (current) drug therapy is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .

What is the ICD-10 code for long term immunosuppressive therapy? ›

Even though ICD-10-CM does not provide a specific code for immunosuppressants, Z79. 899 is used to identify the immunosuppressant therapy.

What is the ICD-10 code for chronic allergies? ›

J30. 9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2023 edition of ICD-10-CM J30.

Does Medicare cover allergy testing? ›

Medicare Part B may cover allergy testing if you meet all the below criteria: Your physician must prescribe the allergy test. Your physician must be enrolled in Medicare and accept assignment. The test must be considered medically necessary, and your physician must provide documentation that says so.

What ICD-10 codes? ›

The International Classification of Diseases, Tenth Revision, Clinical Modification — more commonly known as ICD-10-CM — is a classification system of diagnosis codes representing conditions and diseases, related health problems, abnormal findings, signs and symptoms, injuries, and external causes of injuries and ...

What is the ICD-10 code for allergic reaction to medication? ›

ICD-10-CM Code for Allergy status to other drugs, medicaments and biological substances Z88. 8.

What is the ICD 9 code for allergic reaction? ›

Specific ICD-9-CM codes can identify patients with allergic drug reactions, with antibiotics accounting for almost half of true reactions. Most patients with codes 693.0, 995.1, 708, and 995.0 had allergic drug reactions, with 693.0 as the highest yield code.

What is the ICD-10 code for Allergy to latex? ›

ICD-10-CM Code for Latex allergy status Z91. 040.

What is the CPT code for allergy testing? ›

The Current Procedural Terminology (CPT®) code 95044 as maintained by American Medical Association, is a medical procedural code under the range - Allergy Testing Procedures.

What does allergy immunotherapy do? ›

Immunotherapy is a preventive treatment for allergic reactions to substances such as grass pollens, house dust mites and bee venom. Immunotherapy involves giving gradually increasing doses of the substance, or allergen, to which the person is allergic.

How do you code allergy shots? ›

Use CPT procedure codes 95115 (single injection) and 95117 (multiple injections) to report the allergy injection alone, without the provision of the antigen.

What is the multiple endoscopy rule? ›

The multiple scope rule requires that you always bundle diagnostic endoscopy with any surgical endoscopy within the same family.

What ICD-10 codes cover allergy testing? ›

ICD-10 code Z01. 82 for Encounter for allergy testing is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .

How do I bill for an allergy test? ›

The MPFSTB fees for allergy testing services must be billed using codes 95004 through 95078, and these are all established for single tests. For this reason, the number of tests administered must always be shown on any billing claim.

Does Medicare pay for allergy test? ›

Medicare Part B may cover allergy testing if you meet all the below criteria: Your physician must prescribe the allergy test. Your physician must be enrolled in Medicare and accept assignment. The test must be considered medically necessary, and your physician must provide documentation that says so.

Is allergy immunotherapy covered by insurance? ›

Allergy shots are a form of immunotherapy that help to reduce allergy symptoms in adults and children. Allergy shots can be expensive but are usually covered by most health insurance plans.

Why are allergy drops not covered by insurance? ›

Insurance companies may cover the cost of office visits and diagnostic testing. Because allergy drops are an off-label use of FDA-approved antigens, they are not typically covered by insurance.

Is immunotherapy covered by insurance? ›

Immunotherapy is an emerging treatment for cancer and other conditions that can be very expensive. These treatments may be covered by private insurance, Medicare, or Medicaid. If you qualify, manufacturer patient assistance programs can help reduce your out-of-pocket costs.

How do I bill CPT 95117? ›

Use code 95115 per encounter for a single injection and 95117 for a single encounter where two or more injections are given. An allergist or other supplier prepares or supervises the preparation of single dose vials of antigens for allergen immunotherapy.

Can 96372 and 95117 be billed together? ›

Per NCCI, 96372 does bundle to 95117, but a modifier is allowed.

Are allergy shots immunotherapy? ›

Allergy shots are regular injections over a period of time — generally around three to five years — to stop or reduce allergy attacks. Allergy shots are a form of treatment called immunotherapy. Each allergy shot contains a tiny amount of the specific substance or substances that trigger your allergic reactions.

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