LCD Reference Article Billing and Coding Article

Billing and Coding: Allergen Immunotherapy

A57678

Expand All | Collapse All
Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57678
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Allergen Immunotherapy
Article Type
Billing and Coding
Original Effective Date
10/03/2018
Revision Effective Date
09/28/2022
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Internet-Only Manuals (IOMs)

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
    • Chapter 15, Sections 20.2 Physician Expense for Allergy Treatment and 50.4.4.1 Antigens
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 12, Section 200 Allergy Testing and Immunotherapy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L37800 Allergen Immunotherapy. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Please refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 200 Allergy Testing and Immunotherapy for instructions on billing for allergy services.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
  4. Documentation of any therapeutic expectations, level of antigens, time frame for administration, and any adjustments to the expectation based on local reactions, systemic reactions, missed dosing will need to be very clear in the medical records.
  5. Documentation for all references to the therapeutic effective dose in the medical record should be referenced to the maintenance concentrate and should be noted as a volume-to-volume dilution (e.g., 1:100 vol/vol dilution of maintenance concentrate).
  6. In the event that allergen immunotherapy is administered to a patient in a home setting, medical record documentation must clearly demonstrate that the benefits of immunotherapy outweigh the risks, include a copy of the patient’s informed consent, and include validation regarding the training and ability of the individual administering the injection to recognize and manage immunotherapy reactions, particularly anaphylaxis.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
99999 Not Applicable
N/A

CPT/HCPCS Codes

Group 1

(9 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
Code Description
95115 Immunotherapy one injection
95117 Immunotherapy injections
95144 Antigen therapy services
95145 Antigen therapy services
95146 Antigen therapy services
95147 Antigen therapy services
95148 Antigen therapy services
95149 Antigen therapy services
95165 Antigen therapy services

Group 2

(1 Code)
Group 2 Paragraph

N/A

Group 2 Codes
Code Description
95170 Antigen therapy services

Group 3

(1 Code)
Group 3 Paragraph

N/A

Group 3 Codes
Code Description
95180 Rapid desensitization
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(77 Codes)
Group 1 Paragraph


It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, and 95165:

Group 1 Codes
Code Description
H10.411 Chronic giant papillary conjunctivitis, right eye
H10.412 Chronic giant papillary conjunctivitis, left eye
H10.413 Chronic giant papillary conjunctivitis, bilateral
H10.45 Other chronic allergic conjunctivitis
J30.0 Vasomotor rhinitis
J30.1 Allergic rhinitis due to pollen
J30.2 Other seasonal allergic rhinitis
J30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander
J30.89 Other allergic rhinitis
J31.0 Chronic rhinitis
J45.20 Mild intermittent asthma, uncomplicated
J45.30 Mild persistent asthma, uncomplicated
J45.40 Moderate persistent asthma, uncomplicated
J45.50 Severe persistent asthma, uncomplicated
T63.421A Toxic effect of venom of ants, accidental (unintentional), initial encounter
T63.421D Toxic effect of venom of ants, accidental (unintentional), subsequent encounter
T63.421S Toxic effect of venom of ants, accidental (unintentional), sequela
T63.422A Toxic effect of venom of ants, intentional self-harm, initial encounter
T63.422D Toxic effect of venom of ants, intentional self-harm, subsequent encounter
T63.422S Toxic effect of venom of ants, intentional self-harm, sequela
T63.423A Toxic effect of venom of ants, assault, initial encounter
T63.423D Toxic effect of venom of ants, assault, subsequent encounter
T63.423S Toxic effect of venom of ants, assault, sequela
T63.424A Toxic effect of venom of ants, undetermined, initial encounter
T63.424D Toxic effect of venom of ants, undetermined, subsequent encounter
T63.424S Toxic effect of venom of ants, undetermined, sequela
T63.441A Toxic effect of venom of bees, accidental (unintentional), initial encounter
T63.441D Toxic effect of venom of bees, accidental (unintentional), subsequent encounter
T63.441S Toxic effect of venom of bees, accidental (unintentional), sequela
T63.442A Toxic effect of venom of bees, intentional self-harm, initial encounter
T63.442D Toxic effect of venom of bees, intentional self-harm, subsequent encounter
T63.442S Toxic effect of venom of bees, intentional self-harm, sequela
T63.443A Toxic effect of venom of bees, assault, initial encounter
T63.443D Toxic effect of venom of bees, assault, subsequent encounter
T63.443S Toxic effect of venom of bees, assault, sequela
T63.444A Toxic effect of venom of bees, undetermined, initial encounter
T63.444D Toxic effect of venom of bees, undetermined, subsequent encounter
T63.444S Toxic effect of venom of bees, undetermined, sequela
T63.451A Toxic effect of venom of hornets, accidental (unintentional), initial encounter
T63.451D Toxic effect of venom of hornets, accidental (unintentional), subsequent encounter
T63.451S Toxic effect of venom of hornets, accidental (unintentional), sequela
T63.452A Toxic effect of venom of hornets, intentional self-harm, initial encounter
T63.452D Toxic effect of venom of hornets, intentional self-harm, subsequent encounter
T63.452S Toxic effect of venom of hornets, intentional self-harm, sequela
T63.453A Toxic effect of venom of hornets, assault, initial encounter
T63.453D Toxic effect of venom of hornets, assault, subsequent encounter
T63.453S Toxic effect of venom of hornets, assault, sequela
T63.454A Toxic effect of venom of hornets, undetermined, initial encounter
T63.454D Toxic effect of venom of hornets, undetermined, subsequent encounter
T63.454S Toxic effect of venom of hornets, undetermined, sequela
T63.461A Toxic effect of venom of wasps, accidental (unintentional), initial encounter
T63.461D Toxic effect of venom of wasps, accidental (unintentional), subsequent encounter
T63.461S Toxic effect of venom of wasps, accidental (unintentional), sequela
T63.462A Toxic effect of venom of wasps, intentional self-harm, initial encounter
T63.462D Toxic effect of venom of wasps, intentional self-harm, subsequent encounter
T63.462S Toxic effect of venom of wasps, intentional self-harm, sequela
T63.463A Toxic effect of venom of wasps, assault, initial encounter
T63.463D Toxic effect of venom of wasps, assault, subsequent encounter
T63.463S Toxic effect of venom of wasps, assault, sequela
T63.464A Toxic effect of venom of wasps, undetermined, initial encounter
T63.464D Toxic effect of venom of wasps, undetermined, subsequent encounter
T63.464S Toxic effect of venom of wasps, undetermined, sequela
T63.481A Toxic effect of venom of other arthropod, accidental (unintentional), initial encounter
T63.481D Toxic effect of venom of other arthropod, accidental (unintentional), subsequent encounter
T63.481S Toxic effect of venom of other arthropod, accidental (unintentional), sequela
T63.482A Toxic effect of venom of other arthropod, intentional self-harm, initial encounter
T63.482D Toxic effect of venom of other arthropod, intentional self-harm, subsequent encounter
T63.482S Toxic effect of venom of other arthropod, intentional self-harm, sequela
T63.483A Toxic effect of venom of other arthropod, assault, initial encounter
T63.483D Toxic effect of venom of other arthropod, assault, subsequent encounter
T63.483S Toxic effect of venom of other arthropod, assault, sequela
T63.484A Toxic effect of venom of other arthropod, undetermined, initial encounter
T63.484D Toxic effect of venom of other arthropod, undetermined, subsequent encounter
T63.484S Toxic effect of venom of other arthropod, undetermined, sequela
T78.49XA Other allergy, initial encounter
T78.49XD Other allergy, subsequent encounter
T78.49XS Other allergy, sequela

Group 2

(12 Codes)
Group 2 Paragraph


It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 95170:

Group 2 Codes
Code Description
T63.421A Toxic effect of venom of ants, accidental (unintentional), initial encounter
T63.421D Toxic effect of venom of ants, accidental (unintentional), subsequent encounter
T63.421S Toxic effect of venom of ants, accidental (unintentional), sequela
T63.422A Toxic effect of venom of ants, intentional self-harm, initial encounter
T63.422D Toxic effect of venom of ants, intentional self-harm, subsequent encounter
T63.422S Toxic effect of venom of ants, intentional self-harm, sequela
T63.423A Toxic effect of venom of ants, assault, initial encounter
T63.423D Toxic effect of venom of ants, assault, subsequent encounter
T63.423S Toxic effect of venom of ants, assault, sequela
T63.481A Toxic effect of venom of other arthropod, accidental (unintentional), initial encounter
T63.481D Toxic effect of venom of other arthropod, accidental (unintentional), subsequent encounter
T63.481S Toxic effect of venom of other arthropod, accidental (unintentional), sequela

Group 3

(84 Codes)
Group 3 Paragraph


It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 95180:

Group 3 Codes
Code Description
T36.0X5A Adverse effect of penicillins, initial encounter
T36.0X5D Adverse effect of penicillins, subsequent encounter
T36.0X5S Adverse effect of penicillins, sequela
T36.1X5A Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter
T36.1X5D Adverse effect of cephalosporins and other beta-lactam antibiotics, subsequent encounter
T36.1X5S Adverse effect of cephalosporins and other beta-lactam antibiotics, sequela
T36.4X5A Adverse effect of tetracyclines, initial encounter
T36.4X5D Adverse effect of tetracyclines, subsequent encounter
T36.4X5S Adverse effect of tetracyclines, sequela
T36.8X5A Adverse effect of other systemic antibiotics, initial encounter
T36.8X5D Adverse effect of other systemic antibiotics, subsequent encounter
T36.8X5S Adverse effect of other systemic antibiotics, sequela
T37.0X5A Adverse effect of sulfonamides, initial encounter
T37.0X5D Adverse effect of sulfonamides, subsequent encounter
T37.0X5S Adverse effect of sulfonamides, sequela
T37.1X5A Adverse effect of antimycobacterial drugs, initial encounter
T37.1X5D Adverse effect of antimycobacterial drugs, subsequent encounter
T37.1X5S Adverse effect of antimycobacterial drugs, sequela
T39.015A Adverse effect of aspirin, initial encounter
T39.015D Adverse effect of aspirin, subsequent encounter
T39.015S Adverse effect of aspirin, sequela
T39.095A Adverse effect of salicylates, initial encounter
T39.095D Adverse effect of salicylates, subsequent encounter
T39.095S Adverse effect of salicylates, sequela
T48.6X5A Adverse effect of antiasthmatics, initial encounter
T48.6X5D Adverse effect of antiasthmatics, subsequent encounter
T48.6X5S Adverse effect of antiasthmatics, sequela
T48.995A Adverse effect of other agents primarily acting on the respiratory system, initial encounter
T48.995D Adverse effect of other agents primarily acting on the respiratory system, subsequent encounter
T48.995S Adverse effect of other agents primarily acting on the respiratory system, sequela
T50.8X5A Adverse effect of diagnostic agents, initial encounter
T50.8X5D Adverse effect of diagnostic agents, subsequent encounter
T50.8X5S Adverse effect of diagnostic agents, sequela
T50.Z95A Adverse effect of other vaccines and biological substances, initial encounter
T50.Z95D Adverse effect of other vaccines and biological substances, subsequent encounter
T50.Z95S Adverse effect of other vaccines and biological substances, sequela
T50.995A Adverse effect of other drugs, medicaments and biological substances, initial encounter
T50.995D Adverse effect of other drugs, medicaments and biological substances, subsequent encounter
T50.995S Adverse effect of other drugs, medicaments and biological substances, sequela
T63.441A Toxic effect of venom of bees, accidental (unintentional), initial encounter
T63.441D Toxic effect of venom of bees, accidental (unintentional), subsequent encounter
T63.441S Toxic effect of venom of bees, accidental (unintentional), sequela
T63.442A Toxic effect of venom of bees, intentional self-harm, initial encounter
T63.442D Toxic effect of venom of bees, intentional self-harm, subsequent encounter
T63.442S Toxic effect of venom of bees, intentional self-harm, sequela
T63.443A Toxic effect of venom of bees, assault, initial encounter
T63.443D Toxic effect of venom of bees, assault, subsequent encounter
T63.443S Toxic effect of venom of bees, assault, sequela
T63.444A Toxic effect of venom of bees, undetermined, initial encounter
T63.444D Toxic effect of venom of bees, undetermined, subsequent encounter
T63.444S Toxic effect of venom of bees, undetermined, sequela
T63.451A Toxic effect of venom of hornets, accidental (unintentional), initial encounter
T63.451D Toxic effect of venom of hornets, accidental (unintentional), subsequent encounter
T63.451S Toxic effect of venom of hornets, accidental (unintentional), sequela
T63.452A Toxic effect of venom of hornets, intentional self-harm, initial encounter
T63.452D Toxic effect of venom of hornets, intentional self-harm, subsequent encounter
T63.452S Toxic effect of venom of hornets, intentional self-harm, sequela
T63.453A Toxic effect of venom of hornets, assault, initial encounter
T63.453D Toxic effect of venom of hornets, assault, subsequent encounter
T63.453S Toxic effect of venom of hornets, assault, sequela
T63.454A Toxic effect of venom of hornets, undetermined, initial encounter
T63.454D Toxic effect of venom of hornets, undetermined, subsequent encounter
T63.454S Toxic effect of venom of hornets, undetermined, sequela
T63.461A Toxic effect of venom of wasps, accidental (unintentional), initial encounter
T63.461D Toxic effect of venom of wasps, accidental (unintentional), subsequent encounter
T63.461S Toxic effect of venom of wasps, accidental (unintentional), sequela
T63.462A Toxic effect of venom of wasps, intentional self-harm, initial encounter
T63.462D Toxic effect of venom of wasps, intentional self-harm, subsequent encounter
T63.462S Toxic effect of venom of wasps, intentional self-harm, sequela
T63.463A Toxic effect of venom of wasps, assault, initial encounter
T63.463D Toxic effect of venom of wasps, assault, subsequent encounter
T63.463S Toxic effect of venom of wasps, assault, sequela
T63.464A Toxic effect of venom of wasps, undetermined, initial encounter
T63.464D Toxic effect of venom of wasps, undetermined, subsequent encounter
T63.464S Toxic effect of venom of wasps, undetermined, sequela
T80.51XA Anaphylactic reaction due to administration of blood and blood products, initial encounter
T80.51XD Anaphylactic reaction due to administration of blood and blood products, subsequent encounter
T80.51XS Anaphylactic reaction due to administration of blood and blood products, sequela
T80.52XA Anaphylactic reaction due to vaccination, initial encounter
T80.52XD Anaphylactic reaction due to vaccination, subsequent encounter
T80.52XS Anaphylactic reaction due to vaccination, sequela
T80.59XA Anaphylactic reaction due to other serum, initial encounter
T80.59XD Anaphylactic reaction due to other serum, subsequent encounter
T80.59XS Anaphylactic reaction due to other serum, sequela
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this LCD.

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
999x Not Applicable
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
99999 Not Applicable
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
09/28/2022 R2

Article revised and published on 12/22/2022 effective for dates of service on and after 09/28/2022 in response to an inquiry. The ‘ICD-10-CM Codes that Support Medical Necessity’ section for ‘Group 3 Codes’ has been revised to add the following ICD-10-CM codes: T63.441A, T63.441D, T63.441S, T63.442A, T63.442D, T63.442S, T63.443A, T63.443D, T63.443S, T63.444A, T63.444D, T63.444S, T63.451A, T63.451D, T63.451S, T63.452A, T63.452D, T63.452S, T63.453A, T63.453D, T63.453S, T63.454A, T63.454D, T63.454S, T63.461A, T63.461D, T63.461S, T63.462A, T63.462D, T63.462S, T63.463A, T63.463D, T63.463S, T63.464A, T63.464D, T63.464S.

07/11/2021 R1

Article effective for dates of service on and after 7/11/2021.

Final article posted on 05/27/2021.

Draft article posted on 01/14/2021.

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
12/16/2022 09/28/2022 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A