What Is CPT Code 95165 and How Is It Used?

Current Procedural Terminology (CPT) codes provide a standardized language for medical services and procedures. These five-digit alphanumeric codes, developed and maintained by the American Medical Association (AMA), are widely used by healthcare professionals to describe the services they perform. CPT codes streamline reporting, enhance accuracy, and improve efficiency in healthcare communication and billing. They are essential for processing claims and developing guidelines for medical care review.

CPT code 95165 specifically relates to allergen immunotherapy, a treatment designed to reduce sensitivity to specific allergens over time. This code plays a distinct role in documenting and billing for a particular aspect of this specialized medical service.

Defining CPT Code 95165

CPT code 95165 is officially defined as “Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses).”

“Professional services” indicates that the code covers the expertise and oversight provided by a qualified healthcare professional. This involves medical judgment and adherence to established protocols in managing patient care. It underscores the specialized knowledge required for this aspect of allergen immunotherapy.

The phrase “supervision of preparation and provision” clarifies that this code covers the oversight and actual supply of the antigen solution. It is not simply for manufacturing a product, but for the medical professional’s involvement in ensuring the correct formulation and availability of the treatment. This supervision extends to the precise mixing and handling of these biological substances.

“Antigens for allergen immunotherapy” refers to the specific substances used in allergy shots. Antigens are extracts from allergens, such as pollen, dust mites, or insect venom, that are administered to a patient to gradually desensitize their immune system.

The term “single or multiple antigens (specify number of doses)” indicates that the code applies whether the prepared solution contains one type of antigen or a mixture of several. When billing, the number of doses prepared must be specified. For Medicare billing, a dose is defined as a 1cc aliquot of extract, even if smaller aliquots are clinically administered.

The Service Encompassed by CPT 95165

CPT code 95165 represents the specific activities involved in preparing and providing the customized antigen solutions for a patient’s allergen immunotherapy. Preparation involves the precise mixing of various allergens into a solution, often involving multiple dilutions to reach the appropriate concentration for a patient’s treatment phase. The customized nature of this preparation is essential, as each patient’s allergy profile and treatment plan are unique.

The professional’s supervision ensures accuracy and adherence to medical protocols throughout the preparation process. This oversight includes the medical decision-making related to the specific antigen mix and its concentration, based on the patient’s history and prior test results.

Provision refers to making the prepared antigen solution available for administration, whether it is for immediate use or for a series of future injections. This service is distinct from the actual injection or administration of the allergy shot itself. The administration of the injection is billed separately under different CPT codes, such as 95115 or 95117.

Role in Medical Coding and Reimbursement

CPT code 95165 functions as a standardized communication tool within the healthcare system, primarily for billing and reimbursement purposes. It allows healthcare providers to uniformly describe the specific service of antigen preparation and supervision to insurance companies and other payers. This standardization helps ensure that services are consistently categorized and understood across different entities.

Allergists, immunologists, and clinics specializing in allergy treatment typically utilize this code. These providers are responsible for preparing and supplying the allergenic extracts necessary for patient treatment. The code enables them to seek reimbursement for the professional work and resources involved in creating these specialized antigen solutions.

Accurate medical record-keeping is fundamental to supporting the use of CPT code 95165. Documentation must clearly reflect the professional supervision, the details of antigen preparation, and the provision of the antigens. This includes the date of mixing, the number of doses prepared under supervision, patient symptoms, diagnoses, and the proposed treatment plan. Comprehensive documentation is essential for demonstrating medical necessity and facilitating claim processing.

This code allows providers to seek reimbursement for the antigen preparation service, which is separate from the administration of the allergy injection. Reimbursement for 95165 is often based on the number of doses prepared, with specific definitions of a “dose” varying by payer. For instance, Medicare defines a dose as 1cc of extract for billing purposes, allowing a maximum of 10 doses per 10cc vial, even if more aliquots are removed. Understanding these payer-specific guidelines is important for proper billing and avoiding claim denials.