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36.4.2.2 Allergy Testing
The Texas Medicaid Program benefits include specific allergy testing and allergy immunotherapy for clients with clinically significant allergic symptoms. Allergy testing is focused on determining the allergens that cause a particular reaction and the degree of the reaction. Allergy testing also provides justification for recommendations of particular medicines, of immunotherapy, or of specific avoidance measures in the environment.
An initial evaluation of a new patient is considered for reimbursement in addition to allergy testing on the same day.
Established patient visits are not considered for reimbursement in addition to allergy testing on the same day. The allergy testing is considered for reimbursement and the visit is denied as part of another procedure on the same day.
Procedure codes 1-95027 and 1-95199 are not benefits of the Texas Medicaid Program and are denied if submitted for reimbursement.
The following allergy tests are benefits of the Texas Medicaid Program:
• Percutaneous and intracutaneous skin test. The skin test for IgE-mediated disease with allergenic extracts is used in the assessment of allergic clients. The test involves the introduction of small quantities of test allergens below the epidermis. Procedure codes 1-95004, 1-95010, 1-95015, 1-95024, and/or 1-95028 should be used to submit skin tests for consideration of reimbursement.
•Patch or application tests. Patch testing (procedure code 1-95044) is used for diagnosing contact allergic dermatitis.
•Photo or photo patch skin test. Procedure codes 1-95052 and 1-95056 may be used for photo or photo patch skin tests.
•Ophthalmic mucous membrane or direct nasal mucous membrane tests. Nasal or ophthalmic mucous membrane tests (procedure codes 1-95060 and 1-95065) are used for the diagnosis of either food or inhalant allergies and involve the direct administration of the allergen to the mucosa.
•Inhalation bronchial challenge testing (not including necessary pulmonary function tests). Bronchial challenge testing with methacholine, histamine, or allergens (procedure codes 1-95070 and 1-95071) is used for defining asthma or airway hyperactivity when skin testing results are not consistent with the client's medical history. Results of these tests are evaluated by objective measures of pulmonary function.
The type and number of allergy tests performed should be indicated on the claim. When the number of tests is not specified, a quantity of one is allowed.
RAST/MAST Tests
Radioallergosorbent tests (RAST) and multiple antigen simultaneous tests (MAST) are benefits of the Texas Medicaid Program. RAST testing is a radioimmunoassay of the blood serum used to detect specific allergens. MAST is an RAST type test using an enzyme rather than a radioactive marker. RAST/MAST testing is usually performed by an independent lab; however, there are physicians who have the capability of performing these tests in their offices. Physicians who submit RAST/MAST tests performed in the office setting must use modifier SU to be considered for reimbursement. Without the use of the SU modifier, RAST/MAST testing submitted with POS 1 (office) is denied with the message, "Lab performed outside of office must be billed by the performing facility."
RAST/MAST tests should be submitted using procedure codes 5-86003 and 5-86005.
Procedure code 5-86003 should be submitted with a quantity of one and is limited to twelve per year, same provider.
Procedure code 5-86005 should be submitted with a quantity of one and is limited to four (4) per year, same provider.
An allergy injection (1-95120, 1-95125, 1-95130, 1-95131, 1-95132, 1-95133 and 1-95134) is considered for reimbursement in addition to RAST/MAST testing when submitted with the same date of service. Allergy injections will be denied when billed on the same day as any other allergy testing.
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