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IMMUNOTHERAPY

Carlos Posted Fri 06th of April, 2018 17:20:07 PM
What is the proper way to bill for CPT code 95165 preparation and supervision of immunotherapy and the injection code for this 95117 to Humana? They denied our claim stating that for CPT 95165 only 30 units are allowed, we received payment for 30 units but we billed 138 units
SuperCoder Answered Mon 09th of April, 2018 02:51:04 AM

Hi,

> The rule is  “one unit per cc”. However, Medicare does have several caveats as follows, according to chapter 12 of the >Medicare Claims Processing Manual. Below are guidelines for billing 95165, taken from coding alert article. 

  • If a physician prepares a 20cc multi dose vial, he can bill Medicare for 20 doses, since the practice expense is calculated based on the assumption that the physician will remove multiple one cc doses from the vial. “If a physician removes two cc aliquots from this vial, thus getting only 10 doses, he may nonetheless bill Medicare for 20 doses because the practice expense for 20 doses reflects the actual practice expense of preparing the vial.”
  • If a physician removes multiple ½ cc doses from a 10 cc multi dose vial for a total of 20 doses, he can only bill Medicare for 10 doses, which is the maximum billable for the 10 cc vial. “Billing for more than 10 doses would mean that Medicare is overpaying for the practice expense of making the vial,” CMS says.
  • If, however, a physician prepares two 10cc multi-dose vials, he can bill Medicare for 20 doses. But the doctor can remove as many doses from those vials as he wants. “For example, the physician may remove ½ aliquots from one vial, and one cc aliquots from the other vial, but may bill no more than a total of 20 doses,” CMS says.
  • If a physician prepares a five cc multi-dose vial, he can bill Medicare for five doses. However, if the physician removes ten ½ cc doses from the vial, he can still bill only five 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.

However, MUE for 95165 is 30 so you cant bill more than 30 units. Also, please check your payers policy for billing additional units. 

Hope that helps!

Carlos Posted Mon 09th of April, 2018 12:08:57 PM
How about Medicaid? We also received a denial for the same CPT 95165 for an Amerigroup Medicaid claim
SuperCoder Answered Tue 10th of April, 2018 07:02:50 AM

The rules are same for 95165 for medicare and medicaid. 

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