Allergy injections/immunotherapy

Applies to:

All plans

Definition:

Allergen immunotherapy, also known as desensitization or hypo-sensitization, is a medical treatment for some types of allergies, involving exposing patients to small amounts of allergens to change/improve their immune system response to those allergens.

Medical policy:

Allergy Testing / Immunotherapy - 91037

Allergy injections/immunotherapy billing

Allergy and immunotherapy services that are coded incorrectly will be denied or subject to overpayment recoupment.

Allergy services and Evaluation and Management (E/M) services should not be coded for the same date of service unless documentation supports a significant, separately identifiable service. The appropriate modifiers should be appended to the original claim submission.

Allergy testing and allergy immune therapy are not performed on the same date of service based on standard medical practice and should not be coded on the same date of service.

Retesting with the same antigen(s) should rarely be necessary within a three-year period. Claims for retesting within a three-year period should be submitted with documentation of the medical necessity.

Allergy testing

Percutaneous and intracutaneous (intradermal) tests are reported with CPT 95004 or 95024.

  • These are single tests.
  • A unit identifies each different allergen or different dilutions of the same allergen.

Sequential and incremental tests are reported with 95017, 95018 or 95027.

  • Multiple units may be coded based on different allergens or different dilutions of the same allergen.

Single allergy tests should not be coded on the same date as a sequential and incremental tests, and only one test is reimbursed if the same dilution of the same allergen(s) are tested.

Allergy testing is considered an integral component of rapid desensitization kits (CPT 95180). Allergy testing and rapid desensitization kits are not reported or reimbursed separately.

The number of tests per antigen should be reported on the claim.

For interpretation of allergy tests, the appropriate CPT is reported with one unit for each test performed.

Photo patch tests performed with patch or application tests should not be coded for the same date of service. Instead, the more comprehensive photo patch testing (CPT 95052) should be coded.

Allergy immunotherapy

CPT codes 95120-95134 identify allergy immunotherapy services for both professional services and the provision of the allergen extract.

Allergy immunotherapy services for component codes should be used when the rendering provider is not performing the professional services and provision defined for CPT codes 95120 - 95134.

Component codes include CPT codes 95115, 95117, 95144-95170.

  • If both administration and antigen preparation and provision are performed by the same provider, report the appropriate CPT code that accurately describes the professional service and provision of extract.

Professional services for injection of antigen include 95115-95117.

  • This does not include the supply of the antigen.
  • Codes 95115 and 95117 are reimbursed only in an office setting only (POS 11).
  • CPT 96372 should not be coded for allergy related injection services.
  • Administration services are not billable when performed by the member.
  • Code 95115 or 95117 are reported with one unit per date of service. Both codes are not payable on same date of service.

Preparation and provision of a single dose antigen include 95144-95170.

  • Reimbursement is based on a single dose when the code description is specific to single dose. Pay close attention to the full CPT description for accurate coding.
  • Units would reflect the number of doses supplied.
  • Codes 95144 and 95145-95170 are payable in an office setting and hospital outpatient setting (POS 19 and 22).
  • Codes 95145-95170 may also be payable in a skilled nursing facility (POS 31) if a physician is present.

Preparation and provision of allergen immunotherapy for single or multiple antigen extract(s) is reported with 95165.

  • This service includes the preparation of non-venom antigens.

If both administration and provision of the allergen extract is performed by the same physician, report the appropriate CPT code to define this service.

In alignment with CMS, a reasonable supply of antigens should not exceed a supply of more than 12 months for a patient. This is intended to ensure the antigen remains potent and effective over the time these are administered to member.

In vitro testing isn’t payable when a skin test is also performed for the same antigen with the exception of latex sensitivity, Hymenoptera and nut/peanut sensitivity.

In vitro testing must be supported within the medical record as a substitute for in vivo testing (skin testing) and, effective Nov. 11, 2024, will be limited to 30 allergens over a 12-month period.

Preparation and administration

Reimbursement of preparation of reasonable supply of antigens is made when antigens are prepared by a physician (MD or DO) and the physician exam results in a plan of treatment to define the dosage regimen.

  • Documentation must reflect the antigens are administered in accordance with the documented plan of treatment.
  • Administration of the antigen may be performed by the physician or those properly trained, including the member if under the supervision of the physician.

Documentation

Documentation of allergy and immunotherapy services must be detailed in the member’s medical record. This must support medical necessity as defined in the medical policy referenced above.

The medical record must support the accurate CPT coding and units billed, and should include:

  • Allergy test performed along with its interpretation
  • All reactions and complications
  • Testing and plan of treatment that includes dosage regimen
  • Retention of allergy tests in alignment with applicable legal and facility requirements
  • Elements of medical and immunological history
  • Progress notes associated with management during course of allergic disease, treatment length and deviations from the treatment plan or frequency.

Modifiers

Maintenance allergy immunotherapy should be reported with the EJ modifier.