# Xiaflex....ugh. HELP PLEASE!!!



## Laxwido (Aug 18, 2011)

Hi All!

Our Hand Center has been using Xiaflex for the past year, and we are STILL having issues with diff carriers wanting diff CPT's submitted.  Is anyone having luck getting Aetna to pay for the injection?  

I would LOVE to know how others are billing for Xiaflex, and if payer (other than MCR) is actually covering..... The Drug Rep did a GREAT job of selling it to my docs, but so far the reimbursement is NOT delivering 

Any other Hand Center coders, or others with Xiaflex exp. willing to talk?  We can chat via private emails if you don't feel comfortable with the open forum discussion....

Thanks!!

Dawn
ddm9s@virginia.edu


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## astephens (Aug 18, 2011)

what codes are you using?


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## Laxwido (Aug 18, 2011)

For MCR:  20550 day 1, 9921x day 2

Then come the versions:
26989 day 1, 99024 day 2
20550 day 1, 26989 day 2

I've seen others try
20550 day 1, 26340-52 day 2 (52 b/c local anesthesia ONLY)


the Rep wants us to bill (same BIG fee both days...)
26989 day 1, 26989 day 2


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## lavanyamohan (Aug 18, 2011)

Hi,
Billing for Xiaflex™ (collagenase clostridium histolyticum)
XiaflexTM is only indicated for Dupuytren's contractures, ICD-9 code 728.6 (Contracture of palmar fascia).
Day 1
Effective 11/15/2010 and after Providers are instructed to bill CPT code 20550 [Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar “fascia”)], in addition to the drug. Prior to 11/15/2010 providers were instructed to bill CPT code 26989 (Unlisted procedure, hands or fingers).
Day 2
Providers are instructed to bill CPT 99213 which will represent the stretching of the cord and local anesthesia or analgesia and CPT 29130 for the splint application.
Billing for collagenase clostridium histolyticum (Xiaflex™)
01/01/2011 and after; can use code J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg

Regards,
LMohan


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## Laxwido (Aug 18, 2011)

That reads like an official policy.  What carrier released that?  

That is what we use for *MEDICARE ONLY*  If you are using that code set across the board for all your carriers you are losing revenue.

Cigna and Aetna have released coverage policies for Xiaflex using different coding guidance and CPT codes.  
 My questions was, of those who are following the coverage policy codes, are you seeing ANY reimbursement?


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## josephmglick (Aug 19, 2011)

Clinical Policy Bulletin from Aetna's website.

http://www.aetna.com/cpb/medical/data/800_899/0800.html


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## twosmek (Aug 19, 2011)

Our Xiaflex rep helps us out with all our coding (we are just starting to use it) to make sure that the claim will go through clean and even helps with the prior auth.  I suggest calling your local Xiaflex rep.. They are a great resource and know the ins and outs of the insurances

PS. also make sure you are using 90 in the quantity. as the code is for each 0.01 mg and the injection is 0.90 mg


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## twosmek (Aug 19, 2011)

Sorry I re-read and saw that your rep gave you that info.,
Here is what ours gave us. We got a whole binder of stuff..Make sure of course you get your prior authorization--you wont get reimbursement without them.  

We are told to use 20550 with J0775 x 90. (make sure to complete your box 19 with drug name dosage and ndc--to be safe)

next day use 26989 or use E&M and 29130 (dependant on carrier preference)

Hope that helps.

I am assuming that you are in a clinical setting.


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## Laxwido (Aug 19, 2011)

Thanks Tina, for responding.  And yes, I am in a clinical setting!


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## astephens (Aug 19, 2011)

*check this out*

http://www.trailblazerhealth.com/Tools/Notices.aspx?ID=13603&DomainID=1


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## zinknxvl (Aug 22, 2011)

*Xiaflex road blocks*

The Aetna policy that states they cover Xiaflex only addresses the drug and possibly the injection on the first day.  They have since revised their Clinical Policy Guidelines for 'manipulation under anesthesia' to exclude the extension procedure used on day 2 - and they consider the 26989 -the unlisted code - under that policy.  So that reimbursement has been effectively blocked as of 04/29/11 by Aetna.  

 A shame, too, because I really feel it is a break through product for non-surgical treatment.  

The reps also urged us to bill 26989 both day one and day two.  I feel that goes against the 'highest specificity'.  20550 does specify 'aponeurosis'.  From hand anatomy I have researched the contracture is a persistent cord of fibrous (scar or otherwise) tissue that forms in the fascia or aponeurosis. 

If Aetna has already begun putting up roadblocks against reimbursement for components of the treatment proposed in the Xiaflex manual, I am certain that Humana (UGH!) will be fast on their heels.

We had billed the injection, 20550, day one; and an E/M, 26989 on day two.  We had all authorizations in place.  Documentation could have been better, but was sufficient. Still waiting for the first reimbursement for a 26989 in month 13!

The comp code we did use for the 26989 was for manipulation under anesthesia which I clearly appealed was due to work RVU references alone and that the 26989 did not actually represent 27430 (otherwise we would have billed it) because the joint was not manupulated, but the extension of the weakened cord was performed.

I will keep you posted on further developement.


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## Laxwido (Aug 23, 2011)

THANK YOU THANK YOU!!  I so appreciate your feedback!  I am glad I am not the center struggling to get reimbursed.....


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