TMPPM 2010 > Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook > Physician > Procedures and Services > Allergy Services > Allergy Immunotherapy

   
 

6.3.2.1.2 Limitations of Allergy Immunotherapy

The quantity billed for the allergy extract preparation procedure should represent the total number of doses to be administered from the vial. If the number of doses is not stated on the claim, a quantity of one is allowed.

Procedure code 95165 is limited to a total of 160 doses per one-year period, which begins the date the immunotherapy is initiated. Additional doses may be considered for reimbursement through prior authorization with documentation of medical necessity

When an injection is given from a vial, providers should use an administration-only procedure code (95115 or 95117).

An office visit, clinic visit, or observation room visit is not considered for reimbursement in addition to the fee for the preparation or the administration of the allergy vial or extract unless the additional visit results in a nonallergy-related diagnosis or a reevaluation of the client's condition.

The following E/M procedure codes submitted with allergy testing or allergy immunotherapy are appropriate only if a significant, separately identifiable service is provided:

Procedure Codes

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

99217

99218

99219

99220

Modifier 25 may be used to identify the significant, separately identifiable E/M service performed by the same physician on the same day as the allergy-related procedure or other service. When billing with modifier 25, the provider must provide documentation to substantiate the use of the modifier in order for services to be considered for reimbursement. Documentation includes, but is not limited to, office or hospital medical records such as history and physical progress notes and lab results, if applicable.

The following procedure codes are denied when billed on the same day by the same provider as procedure codes 96360, 96365, 96372, 96374, 96375, and 96376:

Procedure Codes

95115

95117

95145

95146

95147

95148

95149

95165

95170

95180

Procedure code 95115 is denied when billed on the same day by any provider as procedure code 95117.

Procedure code 95145 is denied when billed on the same day by any provider as procedure codes 95146, 95147, 95148, and 95149.

Procedure code 95146 is denied when billed on the same day by any provider as procedure codes 95147, 95148, and 95149.

Procedure code 95147 is denied when billed on the same day by any provider as procedure codes 95148 and 95149.

Procedure code 95148 is denied when billed on the same day by any provider as procedure code 95149.

Allergen immunotherapy that is considered experimental, investigational, or unproven is not a benefit of Texas Medicaid.

Single dose vials (procedure code 95144) are not a benefit of the Medicaid program.


Texas Medicaid & Healthcare Partnership
CPT only copyright 2009 American Medical Association. All rights reserved.
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