Inhalant Allergen Immunotherapy

Immunotherapy for inhaled allergens (aeroallergens) includes two methods: sublingual and subcutaneous. Let’s investigate each of these.

Sublingual Immunotherapy (SLIT)

For patients who don’t do well with needles, under-the-tongue immunotherapy is a nice alternative. One method of SLIT is FDA-approved: tablets; while the other isn’t yet: liquid extract drops. Of course, FDA approval will impact whether insurance may pay for the therapy or not.

FDA-Approved SLIT Tablets

Currently, the FDA has approved SLIT tablets for three allergens:

Grass

Ragweed

Dust mites

The coding for SLIT tablets is a little tricky. Why? Because there’s no CPT code for SLIT – even for the first dose administered in the office. So what are your options?

Well, you may lean toward CPT 95076, for an ingestion challenge, but this won’t work. This code is for a diagnostic test that requires sequential and incremental ingestion of the food or drug. And that’s not what’s happening with SLIT.

A possible alternative is to use an E/M code – if the doctor administers the first dose during an education/counseling session. For this to be appropriate, the physician could explain how to take the tablet, what the possible reactions could be (including anaphylaxis), how to use an epinephrine auto-injector, and so forth. The physician must spend this time with the patient and should document all these items of medical care in the chart.

Finally, sublingual immunotherapy tablets are not FDA-approved for anyone over the age of 65. As a result, Medicare doesn’t cover sublingual immunotherapy.

Liquid Extract Drops

This form of treatment is not FDA-approved, so insurance may not pay for it at all. In fact, some carriers consider this to be experimental.

As you’d expect, there’s no CPT code for this.

So what should you do? We recommend you check with the insurance company first to see if they reimburse for this service. Do this before providing the treatment to the patient! Currently, the majority of third-party payers don’t pay for SLIT drops. It’s OK to charge the patient cash if they’re willing and able to pay for the therapy.

Coding for subcutaneous immunotherapy is much clearer.

Subcutaneous Immunotherapy (SCIT)

For managers/billers unfamiliar with different types of SCIT, let’s do a quick review of the three methods we’ll be discussing. Keep in mind the times shown are only examples and can vary.

Now let’s take a look at the coding for each of these.

Conventional SCIT Coding

• 95115

  This code is for "professional services for allergen immunotherapy not including provision of allergenic extracts; single injection."

   

  Note

  This code is mutually exclusive with 95117.

• 95117

  This code is for "2 or more injections."

   

  Note

  This code is mutually exclusive with 95115. Also, you can bill 95117 only once, even if you give three or more injections.

• 95165

  “Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses).”

To sum these up, you’ll bill either 95115 or 95117 for the administration of the injection. You cannot bill both on the same day.

For 95165, you’ll bill the number of anticipated doses per your buildup schedule. Billing for 95165 can be complicated, and it differs for Medicare and commercial payers. We won’t review it here, so for more information, check out our webinar Everything You Wanted to Know about CPT 95165 or our 15-minute educational module Allergy Office: Coding 95165.

Cluster (Accelerated) and Rush (Rapid Desensitization) SCIT

There isn’t a specific CPT code for cluster or rush immunotherapy – but there is a time-based code for rapid desensitization: 95180. Since both cluster and rush immunotherapy are forms of rapid desensitization, this is the code we recommend for both.

Here’s how 95180 works:

• It’s based on time – you’re paid by the hour.
• Time means the total time spent to administer doses and to closely and carefully monitor the patient throughout the desensitization process. This includes taking vital signs, doing careful observation between each injection, etc. There’s significant physician work and significant risk (anaphylaxis) with this type of SCIT.
• The billing formula for 95180 looks like this:
  1. 95180: Rapid desensitization procedure, each hour (e.g., insulin, penicillin, equine serum)
  2. Charge by time: # _____ hours = # ______ units
  3. Time equals total time spent to administer doses and to closely and carefully monitor the patient throughout the desensitization procedure.
  4. A minimum of 31 minutes (just over half the time) is required to bill the first hour, and a minimum total of 91 minutes is required to bill a second hour.
• Since you’re billing by the number of hours, documentation is especially key! Use a flowchart to support the time it takes for desensitization. Also, be sure to document the medical necessity for the procedure.

  Document, document, document!

• Note: 95180 includes administration, so don’t bill with 95115 or 95117.
• It’s likely that extract preparation (95165) has already been billed. If this is the case, don’t bill for it again.

When it comes to coding and billing for rapid desensitization, it’s wise to check with your payers for their coverage guidelines regarding diagnoses. Some insurance may cover 95180 for certain diagnoses (venom, drug, inhalant allergies, etc.) but not others. As you know, ICD-10 and CPT codes must be paired, so make sure the diagnosis you’re using is appropriate for 95180.

In general, Medicare and Medicaid pay for both cluster and rush therapy. However, local carriers may have different coverage than the national carrier. So always check with your local carrier to find out what their particular policy is.

How are you doing with all of this? Perhaps a couple of examples would help cement everything in your mind.

So that’s how you code for inhalant allergen immunotherapy. Next, let’s tiptoe carefully into the venturesome world of venoms.

College Coding Resources

1. Immunotherapy Coding Essentials Our coding experts, M. Razi Rafeeq, MD, FACAAI, and Mike Tankersley, MD, MBA, FACAAI, do a deep dive into the coding for various types of immunotherapy in this webinar. (July 18, 2019)
2. College Coding Toolkit