Jeffrey Posted Tue 15th of November, 2016 10:35:32 AM
This is in regards to CPT stinging insect codes 95145-95149. We have a patient who is allergic to 4 stinging insects. According to CPT guidelines (CPT assistant May 1996) these codes describe the dose prepared. Our physician prepares a dose containing one insect, that would be CPT code 95145. He then then prepares another dose that contains 3 insects, that would be CPT code 95147. I am seeing conflicting information on how to report this situation. According to the AMA it should be billed as 95145 and 95147. In other coding articles I have seen that this should be billed as 95148. We have contact the AMA on this in the past and they stated “It would not be appropriate to report code 95148 as this code represents one extract containing four different stinging insect venoms” (this is also stated in the CPT assistant May 1996). Can you please clarify the correct reporting of this situation?
SuperCoder Answered Wed 16th of November, 2016 08:50:27 AM
As per coding guidelines, this range of codes is reported by the physicians on the basis of preparation of an antigen for allergen immunotherapy and the provision of the antigen extract itself, which is also includes calculations for the concentration and volume to be used in the dosage based upon the patient's previous skin test results and personal history. To select the appropriate code always look for the number of doses specified and the vial(s) (series of vials from a treatment board or one multiple dose vial) from which the dose may be drawn is irrelevant. Report the code based on the type of preparation, i.e., the number of different venoms contained in a single administered injection of the extract. Report 95145 for a dose containing one single stinging insect venom, 95146 for an extract containing two single stinging insect venoms, 95147 for three, 95148 for four, and 95149 for five single stinging insect venoms in one dose extract. So, in your case there is one insect dose for one drug and three insects of another same drug is being given, for which CPT code 95145 and CPT 95147 is appropriate to code.
Jeffrey Posted Thu 15th of December, 2016 09:11:15 AM
Thank you for the response. I do have a few questions on these codes in regards to Medicare. The CMS Claims Processing Manual Chapter 12 section 200 states that the coding situation I describe above should be billed as 95148. The fist few sentences confirm the AMA coding guidelines. For example “a dose of 95148 means getting some of four venoms.” Later in the same paragraph it says “95148 is to be billed for a patient in four venom therapy”. It removes the word “dose”. This appears to change the meaning of the code.
I asked our Medicare carrier about this; they said they must direct provider coding questions to the AMA. They referenced the CMS IOM PUB 100-09 Chapter 6 Section 30.1.1. That section says the provider must ask the AMA CPT coding questions. I called and spoke to our Medicare carrier; they said we need to follow the CMS manual if we have any coding questions about that manual we need ask the AMA. I asked him if the AMA coding policy contradicts the CMS manual are to bill according to AMA guideline? He said yes.
I asked one of the Academies we are members with and they said we should bill this situation as 95148. I pointed out the contradiction and also that it looks like Medicare changed the definition of the CPT code. They could not explain this.
It is my understanding that the AMA owns the rights to the CPT codes and no payer including Medicare can change the definition of a CPT code. Is that correct?
Is the Medicare policy wrong?
How should this situation be billed to Medicare?
How should this situation be billed to a private payer?
I would appreciate any advice you have on this subject. There seems to be a lot of confusion on these codes.
SuperCoder Answered Fri 16th of December, 2016 08:58:37 AM
I understand your confusion, which is far more correct. CPT is the property of AMA. No one can make any change into it than AMA. In your doubt about doses- when we are talking about doses it means=therapy and vise a versa. CMS creates the policies related to the procedures according to the diagnosis. According to the CMS- Venom doses are prepared in separate vials and not mixed together. Example, if dose of code 95146 (the two-venom code) means getting some of two venoms. Similarly, a dose of code 95147 means getting some of three venoms; a dose of code 95148 means getting some of four venoms; and a dose of 95149 means getting some of five venoms. Questions arise when the administration of these venoms does not remain synchronized because of dosage adjustments due to patient reaction. Use of a code for the venom treatment number for the particular patient should occur only for the purpose of catching up. So, according to this you can select the code. Hope this clear your doubts.
Jeffrey Posted Fri 16th of December, 2016 10:24:34 AM
I just want to make sure I understand your answer. This is in regards to the original example. A patient is allergic to 4 venoms. We prepare a dose containing one insect; at the same time we prepare a dose that that contains 3 insects. The patient will then be given two different injections. If this is a private payer that follows the AMA guidelines we are to bill this situation as 95145 and 95147. If this is a Medicare patient or a payer that follows Medicare policy we are to bill this situation as 95148? The reason for this is because there is a difference between the AMA and Medicare as to what a dose is? The AMA states one dose equals one administered injection of the venom and Medicare says it’s how many total venoms are given regardless of the number injections? Is this correct?
SuperCoder Answered Mon 19th of December, 2016 07:47:56 AM
Yes, you are correct at part. CMS decide the payment policies for the procedure codes according to the payer¸ state(s) and nationally as well. So, you have to check the policy you are billing for. If you are following the AMA direct guidelines then bill according to them, otherwise there may be chances of denial. On the other hand, if your paying pattern is according to CMS then bill according to them. As CMS states, Venom doses are prepared in separate vials and not mixed together, so bill it according to the number of venoms used as described previously. Hope it clears your doubts.