Resources used in allergen immunotherapy differ from CMS assumptions for CPT 95165
Based on our analysis, we found that data used by CMS to calculate practice expense inputs for CPT code 95165 are not accurate. The CMS estimates that in a typical practice, physicians provide immunotherapy from 10 cc multidose vials in shots of 1 cc each. We found that the median vial size is 4.9 cc and the median injection volume is 0.47 cc. In addition, while the current calculations assume 5 antigens are in each vial of immunotherapy, we found that a typical vial contains approximately 8 antigens. Lastly, while the new definition of a dose incorporates 2.2 minutes of clinical staff time, our research indicates that each dose requires 3.0 to 4.5 minutes to prepare. Practice expense calculations for CPT code 95165 do not factor in the dilution boards the typical provider creates, but the allocation per unit for this expense would probably be minimal.
Almost 75 percent of providers are aware of the new definition of a dose
Nearly three-quarters of immunotherapy providers know about the revision, mainly through their specialty society. However, only 44 percent of all immunotherapy providers have changed their billing as a result. In addition, although the revision was intended for practice expense calculation and billing purposes only, approximately 14 percent of immunotherapy providers have begun giving 1 cc injections or changed other practice patterns. Providers generally prefer the traditional definition of a dose as the amount of antigen given in a single injection over the current or an alternate definition.
CONCLUSION
Based on our analysis of data and information from a random sample of allergists, we conclude that CMS did not have accurate data when it calculated the practice expense component for CPT code 95615. After consulting with CMS, we conclude that CMS should use this report to help refine the practice expense inputs for this code as part of their normal process rather than making an immediate change. Since some physicians modified their practice based on the changes in reimbursement, CMS should emphasize that physicians need modify only their billing to comply with the new definition in any guidance it plans to offer in the future. We also noted that most physicians rely on their specialty societies, rather than CMS or its carriers, for information about Medicare policy changes. Therefore, to ensure physicians are getting accurate information, CMS and the carriers may want to work directly with the societies to explain any policy changes and revisions.
