Regulatory changes that affect coding for immunotherapy.

BACKGROUND: During the past decade, a variety of federal regulations have had a significant impact on the way allergen immunotherapy is reimbursed and how Current Procedural Terminology (CPT) codes are used for this purpose. As mandated by the US Congress, the Centers for Medicare and Medicaid Services (CMS) through the Office of the Inspector General (OIG) targeted immunotherapy codes for scrutiny, because they are some of the most frequently used codes. OBJECTIVE: To examine how federal regulations have affected reimbursement for allergy immunotherapy and other allergy services. METHODS: A review was performed of the OIG survey of allergy immunotherapy and the OIG recommendations on CPT coding compliance guidelines. RESULTS: A preliminary survey found problems with medical appropriateness of allergen immunotherapy. For this reason, the OIG performed a more comprehensive study of 301 physicians using code 95165 to analyze by medical record and billing data whether the new billing rules were being correctly used and found that only 44% of physicians were following the new definition of a billable dose. In the early 1990s, the federal government served notice of its intent to more aggressively identify and prosecute health care providers who improperly billed and collected for medical services. Through the adoption of the 1991 US Sentencing Commission Guidelines, the government sought to enhance compliance by mandating lesser criminal penalties for violating organizations that nevertheless maintained and operated "effective compliance plans." In 2002, the OIG audited health care providers and recouped dollar 14.4 billion in improper payments by Medicare. Between January and June 2003, Medicare excluded 1,241 individual providers and health care entities due to fraudulent billing practices. CONCLUSIONS: Federal regulations have significantly affected reimbursement for allergy immunotherapy and other allergy services. Allergists need to be aware of these changes and implement the new recommendations into their practices.

Access to allergy care: implications for quality healthcare and public safety.

Some managed care companies are considering reducing or eliminating coverage for several second-generation antihistamines prescribed to treat patients with allergic rhinitis, chronic idiopathic hives, and other allergy-related conditions. Treatment options for all patients with allergic and immunologic diseases should reflect accepted standards of medical care. Prescription policies limiting coverage and/or use of second-generation antihistamines are medically inappropriate, below current national standards of practice in the field of allergic and immunologic diseases, and may increase health expenditures in the long-term. Any action to reduce or limit coverage will not only diminish the quality of medical care for allergy patients but have significant health and safety implications for the general public.