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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.4 Allergy Services : 9.2.4.2 Allergy Testing

9.2.4.2
Texas Medicaid benefits include allergy testing 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.
The following allergy tests are benefits of Texas Medicaid:
Percutaneous and intracutaneous skin test. The skin test for IgE-mediated disease with allergenic extracts is used in the assessment of allergy-prone clients. The test involves the introduction of small quantities of test allergens below the epidermis. Procedure codes 95004, 95017, 95018, 95024, 95027, and/or 95028 should be used to submit skin tests for consideration of reimbursement.
Patch or application tests. Patch testing (procedure code 95044) is used for diagnosing contact allergic dermatitis.
Photo or photo patch skin test. Procedure codes 95052 and 95056 may be used for diagnosing contact allergic dermatitis.
Ophthalmic mucous membrane or direct nasal mucous membrane tests. Nasal or ophthalmic mucous membrane tests (procedure codes 95060 and 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 95070 and 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.
Procedure code 95199 may be used for an unlisted allergy or clinical immunologic service or procedure if there is not a specific procedure code that describes the service performed. Prior authorization is required for unlisted procedure codes. Every effort must be used to bill with the appropriate CPT code that describes the procedure being performed. If a code does not exist to describe the service performed, prior authorization may be requested using unlisted procedure code 95199 and must be submitted with documentation to assist in determining coverage. The documentation submitted must include all of the following:
Prior authorization requests for Texas Medicaid fee-for-service clients must be submitted by the physician to the Special Medical Prior Authorization (SMPA) department.
The number of allergy tests performed must be indicated on the claim. When the number of tests is not specified, a quantity of one is allowed.
9.2.4.2.1
Allergy blood testing procedure codes 86001, 86003, and 86005 are a benefit when the test is performed for a reason that includes, but is not limited to, the following:
Radioallergosorbent tests (RAST) and multiple antigen simultaneous tests (MAST) are benefits of Texas Medicaid. RAST testing is used to detect specific allergens. RAST 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 must be submitted using procedure codes 86003 and 86005.
Procedure code 86001 is limited to 20 allergens per rolling year, any provider.
Procedure code 86003 is limited to 30 allergens per rolling year, any provider.
Procedure code 86005 is limited to 4 multiallergen tests per rolling year, same provider.
9.2.4.2.2
Collagen skin tests are a benefit of Texas Medicaid using procedure code Q3031. Collagen skin tests are administered to detect a hypersensitivity to bovine collagen. This skin test is given four weeks prior to any type of surgical procedure that utilizes collagen.
Collagen injections that are used for cosmetic surgery are not considered medically necessary and are not a benefit of Texas Medicaid.
9.2.4.2.3
Prior authorization is required for collagen skin test procedure code Q3031.
Prior authorization requests for Texas Medicaid fee-for-service clients must be submitted by the physician to the Special Medical Prior Authorization (SMPA) department.
Prior authorization is not required for other allergy testing procedure codes unless the limits are exceeded. The following medical documentation must be submitted to the SMPA Department with the prior authorization request for additional procedures:
9.2.4.2.4
Ingestion challenge tests are a benefit of Texas Medicaid using procedure code 95076. Ingestion challenge tests are used to confirm an allergy to a food or food additive.
Procedure code 95076 is limited to one service per day, any provider.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.