Revenue Cycle AI
Allergen Immunotherapy Billing
A step-by-step guide to compliant billing for allergen vial preparation (CPT 95144-95165) in a non-profit healthcare system.
Step 1: Billing on Patient's Date of Absence
It is compliant practice to bill for preparing allergen vials on the date the mixing is completed, even if the patient isn't present.
Rationale: These CPT codes represent the professional service of preparation, which is distinct from the injection service.
Official Guidance
- Novitas Solutions (Medicare Contractor): Confirms antigen preparation is a billable service on its own, with the date of service being the day the preparation is rendered. Read More
- AAAAI / ACAAI: A joint statement distinguishing CPT 95165 (preparation) from injection codes, supporting it as a distinct service. Read More
Step 2: Professional (PB) vs. Hospital (HB) Charges
Billing both professional (PB) and hospital (HB) charges depends on your clinic's designation and payer policies.
Professional (PB): Covers the physician’s cognitive work (e.g., determining the formula).
Hospital (HB): Covers overhead like facility use, equipment, and non-physician staff time.
Official Guidance
- CMS Claims Processing Manual: Details that for a hospital outpatient department, the physician's service can be billed separately from the hospital's resources. Read More (See Page 101)
- CGS Administrators (Medicare Contractor): In a hospital outpatient setting (POS 19 or 22), the professional service can be billed alongside a facility claim. Read More
Step 3: Assigning Servicing & Billing Providers
Servicing Provider: The physician or qualified healthcare professional who supervises the vial preparation.
Billing Provider: The healthcare system or hospital entity submitting the claim under its group NPI.
Official Guidance
- Novitas Solutions (Medicare Contractor): Links payment to services "incident to a physician's professional service," making the supervising physician the correct servicing provider. Read More
Step 4: Critical Documentation Requirements
Comprehensive documentation is essential to support medical necessity and billing. Key elements include:
- A Physician's Signed Order
- Detailed Allergen Formulation
- A Mixing Log (dates, lots, preparer)
- Proof of Medical Necessity
- Record of Doses Prepared