We are having a horrible time with UHC not processing our 95165 Antigen claims. We have sent multitudes of appeals and medical records for their review. We are billing antigens every 8-10 weeks at 18 units for most patients. Each of these are being denied for additional info from UHC. When we send all the information it is either radio silence or a redeny stating the notes do not match etc. I have exhausted my medical policy lookup ability and our rep has been unable to give an explanation. Does anyone know the max units per year allowed by UHC or is there something we are missing? I know we are under the MUE of 30 per day.
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Wiki 95165 UHC Continuous Denials
- Thread starter seraphine8519@yahoo.com
- Start date
TThivierge
True Blue
Hi Seraphine8519,
I would use another CPT it states it CPT 95165 is for professional service for preparing multiple doses of insect bugs antigen . Maybe should use CPT 95115-95125 linked with problem..allgery on skin or breathing or mold or Etc. Other factors...CPT Codes 95115 and 95117 - One (1) unit only, when billing for one or more injections given on the same day
Billing guidelines for antigen injections when using CPT Codes 95115 and 95117.
Providers filing claims for the professional services of an injection, which do not include the supply of the antigen serum, should report services using codes 95115 or 95117. Both of these codes are used to report the injection only, and exclude the provision or preparation of the extract not 95165. Code 95115 may be used for a single injection; 95117 covers two or more injections. The correct quantity (number of units) is always one (1) for both codes. Codes 95115 and 95117 should not be billed on the same date of service by the same provider. Report either 95115 or 95117 during a single patient encounter. If one injection is given, report 95115 (only). If two or more injections are given, report 95117 (only).
CPT 95115 - Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection
Only file when giving a single injection
Represents one injection and should be filed with one unit
Cannot be reported with 95117 on the same date of service
CPT 95117 - Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections
Only file when providing multiple injections
Represents multiple injections and should not be billed with multiple units of service. Always bill with one (1) unit
Cannot be filed with 95115 on the same date of service
95117 should be reported just once per patient per date of service
I hope this data helps you!
Lady T
I would use another CPT it states it CPT 95165 is for professional service for preparing multiple doses of insect bugs antigen . Maybe should use CPT 95115-95125 linked with problem..allgery on skin or breathing or mold or Etc. Other factors...CPT Codes 95115 and 95117 - One (1) unit only, when billing for one or more injections given on the same day
Billing guidelines for antigen injections when using CPT Codes 95115 and 95117.
Providers filing claims for the professional services of an injection, which do not include the supply of the antigen serum, should report services using codes 95115 or 95117. Both of these codes are used to report the injection only, and exclude the provision or preparation of the extract not 95165. Code 95115 may be used for a single injection; 95117 covers two or more injections. The correct quantity (number of units) is always one (1) for both codes. Codes 95115 and 95117 should not be billed on the same date of service by the same provider. Report either 95115 or 95117 during a single patient encounter. If one injection is given, report 95115 (only). If two or more injections are given, report 95117 (only).
CPT 95115 - Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection
Only file when giving a single injection
Represents one injection and should be filed with one unit
Cannot be reported with 95117 on the same date of service
CPT 95117 - Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections
Only file when providing multiple injections
Represents multiple injections and should not be billed with multiple units of service. Always bill with one (1) unit
Cannot be filed with 95115 on the same date of service
95117 should be reported just once per patient per date of service
I hope this data helps you!
Lady T
Thank you for the info, we are having the issue when billing the antigen when we have mixed it. We actually haven't been receiving issues with the administrations of the antigen just our billing for the mixing/creation.
zcometa
Networker
We have recently encountered UHC denying due to a recent policy change where they are adopting Medicare guidelines for billing antigen. Therefore, they are only limiting to a max of 10 units/10 cc vial.
l1ttle_0ne
Guru
Are you able to get the 95165 paid when you bill 10 units? We've had a few takebacks by UHC in regards to the 95165. It's when it's billed by itself that they seem to not wan to pay, and I'm unsure if it's the units or something else causing it to deny. One denial they said a modifier or required procedure was missing. and another denial that my a/r person called on and the rep stated that 95165 is an invalid code. I'm just trying to figure these out.
catherinetinkey@entmedicalservices.org
Networker
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- Best answers
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The Medicare guidelines (which a lot of commercial plans are now adopting) defines a dose, for billing purposes only, as 1cc aliquot of extract and does not cover dilution. So if you are doing 10 -.5cc injections out of the vial you would not bill 10 units you can only bill for 5 units because Medicare describes a dose as 1cc aliquot. You can only bill for the # of 1cc doses that are in the vial. The definition of a dose is for billing purposes only and does not dictate the physician's/allergist's treatment. UHC (Optum) is also doing chart/pre-payment reviews for other insurance companies and going by the same guidelines. For any other insurance companies review their allergy medical policies to see if they state a specific amount for a dose.