Part B Insider (Multispecialty) Coding Alert

Always check your insurer’s rules before reporting 96401.

If you dread choosing the right code every time your pulmonologist administers a Xolair injection, you are not alone. The jury is still out on the correct CPT^® code to charge for the service as different payers have different rules. Follow these tips to clear the confusion and hit the bull’s eye every time you bill for your physician.

Background: Xolair (Omalizumab) is a drug prescribed for adults and adolescents (12 years of age or older) with a confirmed diagnosis of moderate to severe persistent allergic asthma, and whose symptoms have been inadequately controlled with other methods, such as inhaled corticosteroids.

Follow the Definition to the Letter for Correct Choice

Problem: No definitive list exists for honing on the right code for Xolair administration as the AMA does not classify any specific drug to an administration code. Absence of clear guidance on this issue means you will have to choose between two available codes:

• 96401 -- Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic
• 96372 -- Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular).

The Xolair categorization debate raged on and whether Xolair warrants using the chemotherapy administration codes was one of the hot items up for discussion. However, neither Xolair nor any other specific medication within the same drug classification has been excluded from 96401.

There has been much controversy over the correct code to select for Xolair administration. “Although categorized as a monoclonal antibody, which would make you lean toward reporting 96401, most payers now require you to report 96372 due to the fact that the use of Xolair is not anti-neoplastic in nature,” informs Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.

Turn to Your Payer for Exact Xolair Interpretation

Coders should check with payers before using 96401 to report omalizumab injections, CPT^® insiders say. Code 96401 was previously used for omalizumab administration.

Why: The confusion was created because according to a list of drugs that qualified for chemotherapy administration codes released by CMS, the agency declared infliximab, rituximab, alemtuzumab, gemtuzumab, and trastuzumab as drugs commonly considered to fall under the category of monoclonal antibodies. The list, however, did not include omalizumab manufactured as Xolair, which many consider as “another drug in the same monoclonal antibody category.”

But, now if you see the notes for 96401, it includes the instructions to use 96372 for non-antineoplastic hormonal therapy injections. Without specific instruction allowing the physician to bill 96401 for Xolair administration, the more appropriate code to report is 96732. Most payers who once allowed reporting of 96401 for Xolair administration have revised their guidelines to only allow 96372.  Please check with your payers for definitive guidance.

For instance, Empire Blue Cross-Blue Shield (Medicare Part B in Illinois state) that earlier indicated that 96401 is indeed appropriate for omalizumab, now have revised their guidelines. According to a release, “BCBSIL is aware of differing opinions among some of the allergists, the coding community and various payers. There have been statements made within the allergy community that CPT^® code 96401 is the code of choice. However, BCBSIL does not believe that Xolair meets the requirements of the chemotherapy CPT^® code of 96401.” Check the BCBSIL release at http://www.bcbsil.com/PDF/bluereview/may_2010.pdf 

Similarly, the corporate reimbursement policy for Blue Cross-Blue Shield North Carolina states that “In accordance with CPT^® guidelines the administration fee for injectable(s) 96372-96376 will be covered in addition to the cost of the drug(s), which are eligible for coverage.” Check more at https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/bundling_guidelines.pdf 

Medicare does not have a national coverage for the Xolair administration and leaves it to local payers for their own rules. Medicare recognizes the supply of the drug with HCPCS code J2357 (Injection, omalizumab, 5 mg). If your physician office doesn’t incur the cost of the drug, the physician/practice will not be reimbursed for the supply of the drug. If your practice is incurring the cost of the drug, you will have to report the supply with the code J2357.

Comply With Medical Necessity Before Billing Xolair

Before billing for Xolair injections, make sure you have fulfilled the coverage conditions for the service. For example, United Healthcare^® stipulates that Xolair injections will be covered only if all the following conditions are met:

• Age 12 years or older;
• Diagnosis of moderate to severe persistent uncontrolled asthma;
• Baseline (pre-omalizumab treatment) serum total IgE level ≥ 30 IU/mL and ≤ 1500 IU/mL;
• Positive skin test or in vitro reactivity to a perennial aeroallergen;
• Documented failure (e.g., emergency room visit or hospitalization for asthma exacerbation, need for oral steroid burst) of at least 3 months to regular/routine treatment with either a inhaled corticosteroid or long-acting beta2-agonist or a combination of both;
• Prescribed by or in consultation with an allergist/immunologist or pulmonologist.

Check the policy details at https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools and Resources/Policies and Protocols/Medical Policies/Drug Policies/Xolair_policy.pdf 

Make sure that you support the Xolair administration with allowed diagnosis codes for smooth reimbursement. Some of acceptable ICD-9 codes include 493.00 (Extrinsic asthma, unspecified), 493.02 (Extrinsic asthma, with [acute] exacerbation), 493.20 (Chronic obstructive asthma, unspecified), and 493.90 (Asthma, unspecified).

Some examples of acceptable ICD-10 codes are J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation), J44.9 (Chronic obstructive pulmonary disease, unspecified), J45.40 (Moderate persistent asthma, uncomplicated), and J45.50 (Severe persistent asthma, uncomplicated). Check your LCD guidelines for exact codes.

Check Out a Case Scenario for Correct Implementation

A completed CMS-1500 form for administration of omalizumab (Xolair) requires four pieces. See if you can identify all four when coding this sample scenario.

Scenario: An established patient who has extrinsic asthma due to house-dust sensitivity comes to the office for administration of Xolair. A nurse administers 50 mg of Xolair by injection into the patient under direct physician supervision and sends him home. You should report:

• 96372
• 493.00 to indicate the medical necessity for the Xolair injection.
• J2357 x 10 units for the supply of Xolair.

Caution: You may wonder about billing an office visit code such as 99211 (Office or other outpatient visit for the evaluation and management of an established patient, …), but you would be leading your claim to rejection. All injection procedures include an assessment of the patient at the encounter (vital signs, appearance of the patient, etc.). Therefore, you should steer clear of reporting E/M codes with 96372 unless you have documentation supporting the need for an additional assessment beyond that for the injection. This can also happen if there are extra-ordinary circumstances, the physician is called in and the injection is abandoned for a higher level E/M.

Extra tip: If multiple injections of Xolair are provided, report the first injection with 96372, and the following injections using 96372 with a suitable modifier. “Private payers may accept modifier 76 (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional) appended, if they do not follow Medicare guidelines,” Pohlig says. However, Medicare identifies modifiers that are permitted with the code, and 76 is not recognized but modifier 59 (Distinct procedural service) and the x-modifiers are allowed with the code,” she adds. 

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