Otolaryngology Coding Alert

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 American College of Chest Physicians Practice Management Committee 2006 article -Incorporating Anti-IgE (omalizumab) Therapy Into Pulmonary Medicine Practice.- For instance, Empire Blue Cross-Blue Shield (Medicare Part B in New York state) recently issued a list of drugs for which code 96401 would be appropriate, indicating that 96401 is indeed appropriate for omalizumab, Marcus tells The Coding Institute.

The added reimbursement rate for using 96401 (1.56 transitional nonfacility total relative value units, RVUs) instead of 90772 (0.53 RVUs) may be justified. More reported cases of anaphylaxis with omalizumab could lead to adding a new warning to the label, Marcus says. -Accordingly, that would mean a longer period of physician observation,- which could justify code 96401.

Beware: Societies Recommend 90772

Although the final CPT verdict on Xolair administration coding is still out, two societies have weighed in on the debate. Because omalizumab is not an anti-neoplastic monoclonal antibody, the American Thoracic Society (ATS) and the American College of Chest Physicians (ACCP) recommend the use of 90772, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

Some payers have followed suit and frown on using chemotherapy administration code 96401 for omalizumab, which is a non-chemotherapy drug. For instance, Cigna Part B for Idaho, North Carolina and Tennessee requires the use of 90772 for Xolair administration. The Medicare carrier agrees that -Xolair (omalizumab) is a monoclonal antibody ... But because Xolair is not an anti-neoplastic as required by 96401, it would be incorrect to bill for administration of Xolair under CPT code 96401, Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.-

Instead the Cigna Government Services July 5, 2006, article -Drug Administration Coding- instructs coders to bill the administration of the drug based on the route of administration using 90772, Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.

CPT confirms that you should use 90772 for non-anti-neoplastic hormonal therapy injections. -Report 96401 for anti-neoplastic hormonal injection therapy.-