Get the Scoop on Xolair Administration Coding

2 societies say omalizumab falls under 90772

If 90772 and 96401 came with a drug reference guide, your coding of omalizumab administration would be a cakewalk.

Problem: No definitive list exists. The AMA does not classify any specific drug to an administration code, says Cindy C. Parman, CPC, CPC-H, RCC, president of the AAPC National Advisory Board and Coding Strategies Inc. in Powder Springs, Ga. 

Clear guidance on this issue is hard to come by, prompting the question: “Should I report the administration of Xolair with a chemotherapy code (96401, Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic) or a therapeutic code (90772, Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular)?” says Jill Young, CPC, an AAPC National Advisory Board member and president of Young Medical Consulting in East Lansing, Mich.
Come to Terms With the Ambiguity
 
Experts expected further clarification from CPT to end the Xolair categorization debate. Whether Xolair warranted using the chemotherapy administration codes was one of the items up for discussion at the CPT’s Drug Infusion Workgroup in 2006, says Vicky O’Neil, CPC, CSS-P, president of The Hazlett Group in St. Louis. “However, neither Xolair nor any other specific medication within the same drug classification were excluded [from 96401],” she says.

Although official guidance on the correct administration code for Xolair still looms on the horizon, pockets of payer-specific guidelines exist. Here’s the latest roundup to keep you up to speed.
Use 96401 Based on Payer Directive
Coders should check with payers before using 96401 to report omalizumab injections, CPT insiders say. “Code 96401 has previously been widely used to administer omalizumab,” says Philip Marcus, MD, MPH, chief of the division of pulmonary medicine at St. Francis Hospital-The Heart Center in Roslyn, N.Y.

Why: CPT’s chemotherapy administration introductory notes allow the use of chemotherapy administration codes for other non-chemotherapy agents, says Stacie Heller, director of health policy affairs for Lash Group, in the December 2005 Oncology Now. The definition created in 2006 meant chemotherapy administration codes can apply to substances, such as monoclonal antibody agents.

Prior to 2006, CMS had created a partial list of drugs that qualified for chemotherapy administration codes. “The following drugs are commonly considered to fall under the category of monoclonal antibodies: infliximab, rituximab, alemtuzumab, gemtuzumab, and trastuzumab,” according to CMS Transmittal 129. But the list did not include omalizumab manufactured as Xolair, which Heller considers as “Another drug in the same monoclonal antibody category.”  

CMS’ partial drug list left discretion to individual carriers. Coding specialists indicate that “certain insurance carriers will reimburse for the more complex code, 96401, generally paid at a higher level, but usually reserved for chemotherapy administration via the subcutaneous route,” says Marcus in the [...]

- Published on 2007-02-28