CPT 95165 Reimbursement Updates for 2025: Key Changes & Best Practices for Allergy Practices

As of 2025, Current Procedural Terminology (CPT) code 95165 remains a cornerstone in allergy and immunology practices, representing the supervision and preparation of antigens for allergen immunotherapy. Given its significance, it's crucial for healthcare providers to stay informed about recent changes in reimbursement rates and payer policies affecting this code.

Medicare Reimbursement Updates

The Centers for Medicare & Medicaid Services (CMS) released the 2025 Medicare Physician Fee Schedule Final Rule, which includes several key updates impacting allergists:

• Conversion Factor Reduction:

  The 2025 conversion factor has been decreased to $32.35, a 2.83% reduction from the 2024 rate of $33.29. This change results in lower reimbursement rates for services billed under CPT 95165.

• Definition of a Dose:

  For Medicare billing purposes, a dose is defined as 1 cc of extract. When preparing a 10 cc multidose maintenance vial, providers may bill a maximum of 10 doses, even if more than ten 1 cc aliquots are administered. This definition is specific to billing and does not dictate clinical practice.

Payer Policy Considerations

While Medicare provides a standardized framework, private payers may have varying policies regarding CPT 95165:

• Documentation Requirements:

  Some insurers may request detailed documentation, including the identity of the prescribing physician, patient information, treatment plans, and signed orders for allergen extracts. However, demands for compounding logs or specific lot numbers are often deemed unnecessary and burdensome.

• Dose Limitations:

  Certain payers impose annual limits on the number of billable doses. For instance, some policies cap CPT 95165 at 150 units per patient per year. It's essential to review each payer's guidelines to ensure compliance and accurate billing.

Best Practices for Compliance

To navigate the evolving landscape of allergen immunotherapy billing:

• Stay Informed:

  Regularly review updates from CMS and private insurers to remain current on policy changes affecting CPT 95165.

• Accurate Documentation:

  Maintain comprehensive records that meet payer requirements, including treatment plans and dosing schedules , to support medical necessity and facilitate smooth claims processing.

• Advocate for Fair Policies:

  Engage with professional organizations, such as the American College of Allergy, Asthma & Immunology (ACAAI) , to advocate against unreasonable payer demands that may hinder patient access to essential therapies.

By adhering to these practices, healthcare providers can ensure compliance, optimize reimbursement, and continue delivering effective allergen immunotherapy to patients.

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Sources

1. American College of Allergy, Asthma & Immunology (ACAAI) - 2025 Medicare Physician Fee Schedule Final Rule
2. ACAAI Guidance - CPT Code 95165: What’s a Dose for Medicare Billing?
3. Healio Allergy News - Guidance on Payer Documentation Requests for Allergen Immunotherapy
4. BridgeSpan Health - Allergy Immunotherapy Reimbursement Policy