Primary Care Coding Alert

Question: How should you code a Synagis injection? Commercial insurers keep denying the procedure. Should I appeal these decisions?

Utah Subscriber

Answer: Before you appeal the denial, check that you coded the procedure properly and that the procedure meets the payer's requirements.
 
1. Verify that you coded the therapeutic injection with 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) and the supply as 90378 (Respiratory syncytial virus immune globulin [RSV-IgIM], for intramuscular use, 50 mg, each). Synagis is an immune globulin (Ig) - not a vaccine. Therefore, you shouldn't have used a vaccine administration code for administering Synagis.
 
2. Make sure that you linked 90378 and 90782 to the baby's gestational period, such as 765.27 (Disorders relating to short gestation and low birthweight; weeks of gestation; 33-34 completed weeks of gestation). Because FPs normally give Synagis to infants with a history of prematurity (less than 35 weeks of gestational age), you should use prematurity as the diagnosis.
 
3. If you submitted the code accurately, you should check with the payer for any software-imposed frequency limitations. For instance, Claim Check has an edit in place that incorrectly limits the number of units allowed per calendar year.
 
4. You should also find out if the payer has any additional filing requirements. Insurers may deny 90782 and 90378 if the procedure doesn't meet certain payer-specific criteria, such as:

   treatment must occur during the respiratory syncytial virus (RSV) season, Oct. 1-April 30

   you administer a total of six doses (a seventh dose may require separate preapproval from the insurer).