Posted and filed under Coding, FWA, Medical Record Auditing.

A medical record audit can reveal over-payments for up-coding, incorrect numbers of units billed, and the abuse of modifiers – just to list a few. Given the popularity of such indiscretions, what is being done after the money is recovered? Do you intend on data mining again in six months, hoping that the provider will change? You may want to review any claim payment policies that are associated with the CPT codes identified in the audit in order to determine which guidelines are being followed. A simple change or clarification of the policies could prevent claims from initial over-payment, and instead grant you the opportunity to report cost projected savings. It is important to take change into consideration after an audit is conducted. Education is the key to avoiding financial loss and the incidence of accidental fraud.

Reflect upon CPT® code 95615, which is described as: “Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)”.

What is a dose?

Per Medicare Excerpts, CPT procedure code 95165 is used to report multiple dose vials of non-venom antigens. Effective January 1, 2001, for CPT code 95165, a dose is now defined as a one- (1) cc aliquot from a single multi-dose vial. When billing code 95165, providers should report the number of units representing the number of 1 cc doses being prepared. A maximum of 10 doses per vial is allowed for Medicare billing, even if more than ten preparations are obtained from the vial. In cases where a multi-dose vial is diluted, Medicare should not be billed for diluted preparations in excess of the 10 doses per vial allowed under code 95165.

Per CPT Assistant, February 2005, pgs. 10-12, Coding Communication: Allergen Immunotherapy. A dose is defined as the amount of antigen(s) administered in a single injection from a multiple dose vial.

These distinctions could be the difference between thousands of dollars and incidences of fraud, waste and abuse. Consider your policies carefully. How is your policy defined? Are you working in accordance with Medicare or CPT? You could be paying for hundreds of doses of CPT code 95165 if your policy and claim payment systems are not synced to limit the amount of units paid to reflect your policy guidelines. Looking at the policies associated with your audit and audit results should be added to your audit procedure in order to prevent future mishaps. Even the best written policies, if not aligned with your payment systems can facilitate over-payments.