Otolaryngology Coding Alert

Follow these expert tips to discover why you shouldn't use 99211, 95115 or 95117

To accurately report Omalizumab (brand name Xolair) injections your allergist administers, you need to understand which codes Medicare and private carriers expect you to report, or you-ll face denials.

CMS Allows G0355 for Monoclonal Antibodies

 If your allergist is administering monoclonal antibodies injections to Medicare patients, you should report temporary code G0355 (Chemotherapy administration, subcutaneous or intramuscular non-hormonal antineoplastic). Because Xolair is an IgE blocker or inhibitor that is classified as a monoclonal antibody, G0355 is the appropriate code to report for Medicare Xolair injections.

-CMS has made it very clear that G0355 may be used to report injections of non-chemotherapy substances and that a cancer diagnosis is not needed,- says Vicky O-Neil, CPC, CCS-P, coding and compliance educator in St. Louis, Mo. -Specifically, they say that this code may be used to report injections of monoclonal antibodies, which Xolair is.-

Private Carriers Prefer 90782

You-ll stand a better chance of getting reimbursement from private carriers in 2005 if you report 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) for Xolair injections.

-The G codes are only for Medicare patients,- says Janette Stauffer, BS, RHIT, CPC, coding services educator with the Wichita Clinic in Kansas. Most other payers do not recognize G codes.

Tip: If your allergist gives multiple injections on the same day, attach modifier 76 (Repeat procedure by same physician) to 90782 to specify that the physician provided multiple injections, says Monica Horner, billing manager and consultant in Pittsburgh. For example, when the physician gives more than one Xolair injection in one day to a patient who requires dosing by weight, report 90782-76.

Be sure to check with your individual payers on how they prefer you to code for Xolair. -Keep in mind that the use of modifiers and CPT codes are payer-specific and their use should be verified,- Horner says.

Note: CPT will delete 90782 and other 907xx series codes in 2006, replacing them with a new set of codes. Look for the latest on CPT changes in the next issue of Otolaryngology Coding Alert.

Avoid 95115, 95117 for Xolair

You may be tempted to report 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or 95117 (... two or more injections), but those codes don't accurately describe Xolair injections.
 
Watch out: Although you might confuse 95115's and 95117's code descriptions with the type of service Xolair injections provide, you should always use the code that best represents the service provided. Codes 95115 and 95117 specify allergy antigen immuno-therapy. Because Xolair is a medication, consisting of antibodies, not allergens, and is not considered an antigen immunotherapy, you shouldn't report these codes in this case.

99211 Isn't a Viable Addition

 Xolair injection services require more dose preparation that most average injection therapies, so you might consider reporting 99211-25 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician; significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to capture additional revenue. Don't fall into this trap.

Rationale: The problem with using 99211 for Xolair injections is that payers already include dose prep and routine patient assessment and monitoring in the RVUs (relative value units, or physician work).

Don't Use J3490 or J3590 Anymore

You no longer need to use the unclassified drug codes J3490 (Unclassified drugs) or J3590 (Unclassified biologics) to report Xolair injections. The 2005 HCPCS code for Xolair is J2357 (Injection, omalizumab, 5 mg). This code is per 5 mg, so make sure you specifically check the number of units on all of your claims, O-Neil says. -The threshold for Xolair patients is 150 mg, so you should always have at least 30 units of J2357 on the claim,- she adds.

Note: If the patient, and not your office, supplied the medication for the injection, you shouldn't report J2357. Physicians are only able to bill for drugs and supplies if they incur direct cost by providing them.