|
8.2.4.1.2 Limitations of Allergy Immunotherapy
The quantity billed for the allergy extract preparation procedure must 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 non-allergy-related diagnosis or a re-evaluation 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:
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. Documentation that supports the provision of a significant, separately identifiable E/M service must be maintained in the client's medical record and made available to Texas Medicaid upon request.
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 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 Texas Medicaid.
|
