CMS CONCLUSION for CPT 95165

CMS CONCLUSION for CPT 95165

The CMS commented on the working draft of this report and concurred with our findings. They indicated, however, that CMS will take no action at this time to address CPT code 95165. The CMS believes that using a 10 cc vial and 1 cc aliquots as the basis for practice expense calculations are not significantly different from using a 5 cc vial and 0.5 cc aliquots. Also, according to CMS, allocating the time and resources spent creating a dilution board to each individual dose would result in a minuscule, if any, change in payment. The clinical staff time required per dose, as stated in the report, requires more study before it could be used as a basis for changing reimbursement. The amount of antigen in a vial, however, is a practice expense issue that CMS has indicated they may address in the future.

With CMS’ comments in mind, we conclude that although the agency did not have accurate data when it calculated the practice expense component for CPT code 95615, there is no compelling need for immediate change. Therefore, CMS could use the information in this report to help refine the practice expense inputs for CPT code 95165 as they see fit, perhaps in conjunction with the next meeting of the Practice Expense Advisory Committee. Since some physicians modified their practice based on the changes in reimbursement, CMS could continue to emphasize that physicians need modify only their billing to comply with the new definition in any guidance it plans to offer in the future. We also noted that most physicians rely on their specialty societies, rather than CMS or its carriers, for information about Medicare policy changes. Therefore, to ensure physicians are getting accurate information, CMS and the carriers may want to work directly with the societies to explain any policy changes and revisions.