Wiki Oral Challenge

[khaslam]

We have a physician who will be performing an oral challenge for a patient in the inpatient setting. I am seeing that 95076 is reimbursed on the outpatient side, but from what I have researched this code does not seem to be paid as an inpatient. Is this correct? Does anyone know the rationale behind this? Is there a different way to bill for an inpatient oral challenge?

 

[thomas7331]

We have a physician who will be performing an oral challenge for a patient in the inpatient setting. I am seeing that 95076 is reimbursed on the outpatient side, but from what I have researched this code does not seem to be paid as an inpatient. Is this correct? Does anyone know the rationale behind this? Is there a different way to bill for an inpatient oral challenge?

Where are you seeing that this is not reimbursed as an inpatient? Professional fees that are allowed in a facility normally don't differentiate between inpatient and outpatient in eligibility for payment.

 

[khaslam]

This is copied from United Healthcare's website. See the last sentence where states it is covered in outpatient setting. The links in the original document bring you to the Medicare NCDs which also state this is only covered in the outpatient setting.

Related Medicare Advantage Coverage Summary
 Allergy Testing and Allergy Immunotherapy
UnitedHealthcare® Medicare Advantage
Policy Guideline
Challenge Ingestion Food Testing (NCD 110.12) Page 2 of 3
UnitedHealthcare Medicare Advantage Policy Guideline Approved 11/14/2018
Proprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.
UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of
determining coverage. It is expected providers retain or have access to appropriate documentation when requested to
support coverage. Please utilize the links in the References section below to view the Medicare source materials used
to develop this resource document. This document is not a replacement for the Medicare source materials that outline
Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the
Medicare source materials will apply.
POLICY SUMMARY
Overview
Challenge ingestion food testing is a safe and effective technique in the diagnosis of food allergies.
This procedure is covered when it is used on an outpatient basis if it is reasonable and necessary for the individual
patient.