Guidance describes unreasonable requests from payors in allergen immunotherapy coding
Key takeaways:
- The guidance addresses CPT codes 95165, 95115 and 95117.
- Payors do not need the credentials of the providers administering injections, the authors said.
- Multiple audit requests also were called unnecessary.
Demands for additional documentation for claims under Current Procedural Terminology codes 95165, 95115 and 95117 are burdensome and unnecessary, according to guidance published in Annals of Allergy, Asthma & Immunology.
The American Academy of Allergy, Asthma & Immunology, American Academy of Otolaryngic Allergy (AAOA) and American College of Allergy, Asthma & Immunology collaborated on this guidance.
Together, these organizations said they aim to help payors develop an efficient and fair process that is not unduly burdensome for reviewing claims submitted under these codes, which cover procedures that are medically necessary for patients with allergic rhinitis, asthma or atopic dermatitis.
Insurance companies and other payors have the right to ensure that claims are for medically necessary and properly coded services performed for the patient, J. Allen Meadows, MD, ACAAI executive director of advocacy and government affairs, and colleagues wrote.
However, the authors also noted increasing demands for multiple, detailed documentation that they considered highly burdensome for physicians as well as generally unnecessary, leading to delays in payment and even nonpayment for appropriate procedures.
“When the excessive requests for medical records and prepayment audits began, many of our members would talk to the insurance companies and their representatives about why they were asking for some of these ridiculous things,” Meadows told Healio.
These companies would respond that there were no guidelines and that they based their requests on publications from medical organizations, Meadows continued, adding that these responses led the AAAAI, AAOA and ACAAI to this collaboration.
“All three organizations are proud of the paper we came up with, and are all in full agreement with it, and I think it was worth the effort,” Meadows said.
Roadblocks
“Allergen immunotherapy is still, even in 2024, one of the few disease-altering therapies that we have,” Meadows said. “If we put the appropriate patient on allergy shots, then we can prevent the progression of allergic rhinitis into asthma.”
But by denying treatment again and again based on failures to meet coding requirements, he continued, insurance companies can get patients to abandon their search for this care.
“That’s the reason they do it,” he said. “If they can get even a small percentage of patients to lose heart and give up, they save money.”
Meadows also noted that the injections involved in allergen immunotherapy are “low dollar but high volume,” ranging in costs from $10 to $15 each.
Insurance audits of these injections may request up to eight different pieces of information.
“If you’re paying an employee $30 an hour to send those eight pieces of information one at a time, pretty quickly, you’re spending 50 bucks to chase 15. The insurance companies know that as well,” Meadows said. “A lot of practices just give up and give in.”
CPT 95165
Specifically, CPT 95165 covers the supervision and preparation of single or multiple antigens for allergen immunotherapy. It also requires providers to specify the number of doses that will be prescribed.
The authors said that it is reasonable for providers to disclose the identity of the physician who established the treatment plan, in addition to the identity of the patient and a brief description of the clinical indications for immunotherapy.
Further, the authors said that a brief description of the treatment plan and the date it was formulated, in addition to a description of the patient’s response to treatment and the need for continued allergen immunotherapy during routine visits, also were reasonable.
Signed and dated orders for allergen extracts, including ingredients, concentrations, volumes and diluents, initialed by the professional compounding the allergen extract, are reasonable as well, the authors continued.
This information entails everything that payors would need to determine the medical necessity and appropriate coding of these services, the authors wrote.
But requiring allergy extracts to be based on a volume of 1 mL or another maximum specific to an insurer, the authors contended, contradicts the standard of practice and is inappropriate.
Each patient is different, and volumes and doses vary, the authors said. Patients may need injections that vary in volume. Also, the authors explained, some antigens cannot be compounded together. The numbers of antigens that can be compounded in a vial may be limited as well.
Claims for extracts that are not based on 1 mL or other predetermined volumes are therefore appropriate, the authors said, adding that annual dose limits should allow variations like these.
The authors asked payors to respect the dosages that physicians have determined when those physicians provide this information.
Further, the authors called demands for compounding logs for each dilution and lot numbers unnecessary for documenting compliance with the code and said they only make the claims process less efficient and more burdensome.
“When we make an allergy shot, in contains several different ingredients. For internal purposes, we record the name of each ingredient, the lot number and the expiration date. All of that is in our internal records,” Meadows said.
However, he said, not many software packages can incorporate these details into the electronic health record very well.
“That makes it difficult to electronically send that information,” Meadows said. “They know that, and that’s why they’re asking for it.”
Claims under 95165 also do not need to include results of allergy skin testing, the authors continued, adding that these requirements are unnecessary and unduly burdensome as well.
95115 and 95117
CPT codes 95115 and 95117 detail subcutaneous injections of extracts specific to each patient in accordance with the dosage schedule that the ordering physician has determined, the authors said, adding that these injections are both approved and necessary for proper treatment.
Like CPT 95165, the author said that requirements for including the injection date and the patient’s name and birth date in the claim are reasonable, as are the volume, dilution and number and site of injections in the dose, nor did the authors object to including the initials or signature of the person administering the injection.
Again, the authors said, this information entails everything that payors would need to be satisfied that treatment has been properly administered.
But the authors contend that requirements for including the vial’s expiration date, the full planned dosing schedule, specifications of subcutaneous administration, the signature of the health care professional who ordered the treatment, the credentials of the person who administered the injection, the injection history and multiple audit requests all are unnecessary and often burdensome.
Unless there is a strong reason for the payor to believe that the person who administered the injection was not following proper protocols, the authors said, requirements for vial expiration dates are unjustified and burdensome.
Requiring the fully planned dosing schedule, the administering professional’s credentials and the injection history are similarly burdensome, they continued, because most injections follow the planned dosing schedule, are administered by credentialed professionals and agree with the injection history.
Specifications of subcutaneous administration are similarly unnecessary, the authors said, since all injections are subcutaneous.
Additionally, once physicians have prescribed and signed off on a treatment schedule, the authors said, there is no need for them to examine the patient before or otherwise sign off on each subsequent injection.
The authors further said that routine claim audits, which can interfere with patient care and delay treatment, only are warranted when payors present evidence that providers have a history of filing incorrect claims.
Follow-up requests for audits are reasonable when providers have not responded to the requirements that the authors considered reasonable, they said, adding that they also are reasonable when payors have evidence of improper administration of injections.
Otherwise, the authors said, requests for multiple audits impose undue burdens, delay prompt payment and have no justification.
Conclusions
Overall, the authors said, requests for documentation showing that treatment is medically necessary and properly performed and coded under CPT 95165, 95115 and 95117 are reasonable, but demands for additional documentation are unreasonable, make the process less efficient and impose undue burdens on providers.
The AAAAI, AAOA and ACAAI said that they would be happy to meet with payors to discuss this guidance so they can craft an efficient and fair process for reviewing claims under these codes that does not impose undue burdens on providers.
Historically, the ACAAI has reached out to the medical directors of insurance companies when protocols became burdensome, Meadows said, adding that he has been involved in many of these discussions himself.
“In the vast majority of these, we come to an amicable solution,” he said.
But over the past 3 years, he continued, medical directors have said that they have been “siloed out” of these protocol decisions.
“We can’t even find out who we’re supposed to talk to,” Meadows said. “Our traditional sources haven’t done it.”
Although Meadows says that he is optimistic about the guidance’s usefulness in making claims easier for allergists, he cautions that practices may need to hire an experienced health care attorney.
Also, Meadows advised practices to make the AAAAI, AAOA and ACAAI aware of any problems they may be experiencing in their claims process.
“We can’t help with problems that we don’t know about,” he said.
Political solutions are options too, Meadows continued, inviting physicians to write to their member of Congress and participate in the ACAAI’s trip to Capitol Hill in Washington, D.C., scheduled for May 7, 2025, to speak with legislators about policy.
Now, the collaborators will share this guidance with the insurance companies.
“I think we’re going to call it a payor education campaign that we’re launching,” Meadows said. “We’re going to use this as a tool to help educate the payors.”
Reference:
- New guidelines for insurers help patients receive necessary allergen immunotherapy treatment. https://acaai.org/news/new-guidelines-for-insurers-help-patients-receive-necessary-allergen-immunotherapy-treatment/. Published Nov. 6, 2024; Accessed Dec. 11, 2024.
Perspective
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Michael S. Blaiss, MD, FACAAI, FAAAAI
The requirements in these codes certainly are burdensome. As clearly articulated in the joint statement, numerous insurance companies are requesting information pertaining to immunotherapy coding that exceeds the necessary requirements to validate the provision of a service.
Since the onset of the COVID-19 pandemic, allergy practices have experienced an increase in overhead expenses and time-consuming practices imposed upon them by insurance companies. Virtually every treatment necessitates prior authorization, significantly augmenting the administrative burden for the practice.
Consequently, a growing number of services are being denied, resulting in an increased workload and staff requirements to address these issues. Furthermore, many insurance companies have prohibited patients from undergoing allergy testing during their initial evaluation, necessitating the scheduling of a second appointment. This practice leads to additional work or school absences for patients.
In essence, these superfluous requirements contribute to the operational expenses of an allergy practice and impose a burden on patients who require allergen immunotherapy but may be unable to continue receiving it due to the coding requirements that result in payment denials.
It would be prudent to address the issue of allergy testing being prohibited during the initial visit. As previously mentioned, this practice imposes a burden on patients. It is evident that the sole reason insurance companies deny allergy testing during the initial visit is the hope that patients may not return to the allergist for testing, thus saving them money. To the best of my knowledge, there is no valid reason for insurance companies to deny this practice.
The codes serve a purpose. Implementing new codes or enhancing the coding process will not address this issue. The problem, as explicitly outlined in these guidelines, is that insurance companies are mandating documentation beyond what is necessary to verify the provision of services. This is the issue that requires resolution.
The allergy organizations and insurance companies should collaborate to develop appropriate verification methods. I sincerely hope that insurance companies will consider the request outlined in the guidelines to engage in discussions with the ACAAI, AAAAI and AAOA to address this matter.
Perspective
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Priya J. Bansal, MD, FAAAAI, FACAAI
To the frustration of clinicians, insurance companies have made their own interpretations and requirements for documentation that are not in line with clinical practice for the formulation and administration of immunotherapy, causing severe burden to practices.
Unfortunately, these burdens severely limit a patient’s access to care, as clinicians may not get reimbursed from the insurance company due to unreasonable requests. The patient may try to call the insurance to get clarity and is often not given correct guidance and may not be able to figure out their out-of-pocket costs to properly budget for their own health care.
I believe that this guidance is a wonderful document to build upon. Now that proper requirements for documentation are clarified, we can work toward helping insurance companies to understand further that even though practices may vary with how they mix extracts in terms of intervals and schedules, billing practices are still in line with mixing practices and guidelines. This will hopefully create more uniform insurance policies for allergy immunotherapy throughout the country, which will in turn provide improved access to our patients for much needed allergy care.
Physicians can continue to advocate for insurance companies to follow published parameters and guidelines and be uniform in their policies. They can also join with patients in these advocacy efforts to demand change.
In the meantime, a simple intervention is for practices to create templates or dot/smart phrases in the EHR that have the recommended needed documentation for allergy immunotherapy and other codes that have guidelines published to reduce the delay of payment and delay of care.
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