As the leader in advocating for allergists and their patients, the Advocacy Council is thrilled to announce that, as a result of our successful meetings with the Medicare Administrative Contractor (MAC) for the Northeast Region – National Government Services – it has agreed to reimburse allergists and other health care professionals for allergen extract dilutions. This service area includes Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, and Wisconsin.
National Government Services made the following statement: “NGS will cover CPT code 95165, when medically reasonable and necessary for preparation and provision of maintenance and build up doses of antigens for allergen immunotherapy.”
This policy only applies to practices in states for which National Government Services is the MAC. Additionally, as previously announced, the Palmetto (Southeast) Region and Noridian (West) Region have adopted similar policies, bringing dilution coverage to 30 states!
However, it is important to note that Medicare has assigned medically unlikely edits (MUEs) of 30 units per day for CPT code 95165. The MUEs are the maximum unit(s) of service that can be reported for a single beneficiary on the same date of service. Claims in excess of the MUE number of units are considered “medically unlikely.” Also, Medicare continues to define a dose as 1ml, unlike the CPT definition.
The Advocacy Council is working to get similar acknowledgments from the other MACs and will keep you informed of our progress. This work is part of our Payer Education Campaign (PEC) that focuses on halting allergen immunotherapy audits and claims denials.
Many members have commented that the changes about dilutions are not found on the specific MACs websites yet. We have email confirmation that the changes reported are accurate. If members are audited or denied payment for dilutions, please report those incidents to the Advocacy Council.
We must also acknowledge the important work done in this effort in partnership with the Advocacy Council by Ned DeLozier of The Allergy, Asthma and Sinus Center and PME Communications, as well as John Herzog of Kimbell & Associates. We also thank Senator Marsha Blackburn (R-TN) and Senator Bill Cassidy, MD (R-LA), for their assistance with CMS in this effort. We also acknowledge the assistance of the Medical Society of the State of New York.
IMPORTANT: The information contained herein is provided for educational purposes only and should not be construed or relied upon as legal advice. If legal advice is required, you should seek the advice of your legal counsel.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
