August 2, 2019
Allergy services

Applicable to: Mercy Care Complete Care, Mercy Care RBHA, Mercy Care Long Term Care, Division of Developmental Disabilities and Mercy Care Advantage
In an effort to assure appropriate billing of allergy services, Mercy Care would like to provide additional clarification.  

The following codes should be used to bill for allergy services: 

  • 95165 - Professional services for the supervision or preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)*

  • 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**

*CPT 95165 is the code to use for extract preparation, regardless of the number of antigens included. Whether you have 1 or 10 antigens in the vial, the code to use is the same.

**When using CPT 95117: Whether you’re giving two or 10 injections – the correct code is 95117. No additional units can be added for additional injections.

Mercy Care follows CMS guidelines, which are recognized as the industry standard.   

Medicare does not follow the CPT definition of a dose when it comes to billing:
  • Medicare Dose:  1 cc (or 1 ml) of extract at the maintenance dose level
  • CPT Dose: The amount of antigen(s) administered in a single injection from a multiple-dose vial

For example, a provider prepares a 10 cc multi-dose vial at maintenance strength. For reimbursement purposes only, Medicare would consider this 10 doses/units. If the provider administers maintenance level injections of 0.5 ccs. You would still bill Medicare 10/units doses of extract with the 10 cc vial. Since giving the shots is different from their preparation – you can bill for the administration of every injection with either 95115 or 95117. (These two codes are mutually exclusive).  

One final Medicare rule to be aware of with code 95165 is that Medicare does not cover dilutions or treatment buildup. They cover maintenance treatment only.

Medically Unlikely Edits of MUE's are claims edits for individual codes that Medicare uses to limit the number of tests or treatments you can provide to a Medicare patient. The MUE for 95165 is the maximum number of services per day that is reasonably expected. Medicare has assigned MUEs of 30 units per day per patient. If this units go over this amount of 30 units in a single day, they are considered "medically unlikely" and they may be denied in the entirety. If you have units greater than 30 units per day, you would have to appeal and provide documentation as to why the units were greater than 30 units. 

Remember, authorization of services is not a guarantee of payment. Once a claim has been received, we have noted large discrepancies in the amount of units billed in comparison to the amount of units authorized, especially from non-allergy specialists.    

To avoid these issues, we encourage providers who are non-allergy specialists to refer their members to an allergist in order that claims be appropriately billed.  

For providers who do not have an allergy specialty and want to continue to provide these services, effective 10/1/2019, the fees payable for these services will reduce to 85% of the AHCCCS Fee Schedule. This would include codes in the range 95004 - 95199 for allergy testing. This will not be decreased for providers with an Allergist and/or Allergy & Immunology primary specialty as registered with Mercy Care. If a provider currently has these as a secondary specialty, they may be able to contact us and have this altered to their primary specialty, as the higher rates will solely be indicated by their primary specialty.

As always, don't hesitate to contact your Mercy Care Provider Relations Representative with any questions or comments. You can find this notice and all other provider notices on our Mercy Care website.  We appreciate your participation in our network and your dedication to the health and welfare of our members and your patients. 

Thanks for all you do!