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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.4 Allergy Services : 8.2.4.1 Allergy Immunotherapy

8.2.4.1
Allergy Immunotherapy
Allergen immunotherapy consists of the parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage which is maintained as maintenance therapy.
Preparation of the allergy vial or extracts is a benefit of Texas Medicaid and should be submitted using the following procedure codes:
Administration of the allergy extract may be reimbursed using procedure codes 95115 and 95117.
The preparation of the allergy vial or extract and the administration of an injection may be reimbursed for the following diagnosis codes:
8.2.4.1.1 Prior Authorization for Allergy Immunotherapy
Authorization is not required for immunotherapy services within the limitations outlined below. Requests for services beyond the established limits may be prior authorized with documentation of medical necessity. Documentation must be submitted to the Special Medical Prior Authorization Department and include the following information:
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.

Texas Medicaid & Healthcare Partnership
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