Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-4 - Physician Services
Section 5160-4-19 - Allergy services
Universal Citation: OH Admin Code 5160-4-19
Current through all regulations passed and filed through September 16, 2024
(A) Purpose. This rule addresses payment for the professional administration and evaluation of allergy sensitivity test procedures, which can be divided into three categories: allergy testing, ingestion challenge testing, and allergen immunotherapy. Payment for related laboratory tests is addressed in Chapter 5160-11 of the Administrative Code.
(B) Coverage.
(1) Allergy testing.
(a)
Testing is only appropriate if there
is a reasonable probability, documented in the individual's medical file,
that the individual was exposed to the antigen being used for the
test.
(b) The unit of service is
the test. Payment may be made only for the fewest number of tests necessary to
reach a diagnosis.
(c) Payment
includes all associated professional services. No payment is made for
evaluation and management unless a separately identifiable service is
performed.
(d) A qualitative
multiallergen screen for allergen-specific immunoglobulin E (IgE) is not
considered to be medically necessary.
(2) Ingestion challenge testing.
(a) The unit of service is the encounter.
Payment may be made only once per visit regardless of the number of items
tested.
(b) Payment includes the
evaluation of the individual's response to the test items.
(3) Allergen immunotherapy.
(a) Payment includes all associated
professional services. No payment is made for evaluation and management unless
a separately identifiable service is performed.
(b) Payment for the antigen is made
separately. No payment will be made for a service that includes administration
(injection) as well as the antigen and its preparation.
(c) The unit of service is the
dose-per-vial.
(d) Separate payment
for the preparation of a single-dose vial of allergen antigen may be made only
if the provider prepares the antigen for injection by another entity.
(e) The date of service is the date on which
the first dose is administered or the date on which the vial is dispensed for
future use.
(f) Immunotherapy is
not considered to be medically necessary for
an allergic reaction to common environmental factors
(such as dust, house plants, or natural fibers) that can be mitigated by other
means.
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