Pulmonology Coding Alert

CPT moves to make 90772 the only choice for these shots

After years of confusion and conflicting information on which code set to choose from, there will finally be some official guidance coming on reporting encounters in which a pulmonologist's staff injects a patient with omalizumab (Xolair).

The verdict: When reporting Xolair shots, use standard injection codes, not chemotherapy administration codes, recommends CPT's Drug Infusion Workgroup.

The workgroup recently met to discuss the application of the injection codes, but no official word has been handed down yet, says Vicky O'Neil, CPC, CSS-P, president of The Hazlett Group in St. Louis. Still, pulmonology coders should get used to injection codes for Xolair, experts say, because it is difficult to justify the higher-paying chemotherapy code when injecting Xolair.

Best bet: Follow this advice when reporting Xolair injections for your patients--and wait for official word soon from CPT.

Asthma Patients Get Xolair Most Often

Xolair is a monoclonal antibody the physician injects to treat asthma. When your office staff injects the substance, you should always report 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for the shot, according to a Cigna Government Services release.

Example: An established patient with atopic asthma comes to the office for an asthma evaluation and for Xolair administration. The pulmonologist sees the patient; then the nurse administers 300mg of Xolair by injection into the patient and sends him home. On the claim, you should:

• report 90772 for the Xolair injection.

• report J2357 (Injection, omalizumab, 5 mg) x 60 for the supply of Xolair.

• report the appropriate evaluation and management (E/M) level from 99211-99215 for the office visit.

• append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to show the E/M was separate from the injection.

• link ICD-9 code 493.00 (Extrinsic asthma; unspecified) to 90772 and the E/M code to indicate the medical necessity for the office visit and the Xolair injection.

Don't forget documentation: You must back your Xolair injection claims with strong documentation, or you're likely to receive rejections.

Check out these documentation requirements for Xolair injections, from Cigna's North Carolina Local Coverage Determination (LCD):

• "Office records must clearly document the reason and frequency for the drug (Xolair) use."

• "The documentation must reflect the dose administered, the current weight of the beneficiary, and the initial IgE level."

• "Office records must also support the continued use of the drug."

• "This information and an appropriate history and physical examination must be available if requested by the carrier to determine coverage."

Shelve Chemo Codes For Xolair Admin

Not only has Cigna instructed providers to use 90772 for Xolair shots, it has also gone out of its way to discourage the use of 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic) for Xolair injections. The Cigna release states, "it would be incorrect to bill for administration of Xolair under 96401."

Why? "Xolair is not an anti-neoplastic, as is required in this code," Cigna reports. Further, the CPT Manual 2006/Professional Edition states "Report 90772 for non-antineoplastic hormonal therapy injections" and "Report 96401 for anti-neoplastic non-hormonal injection therapy."

Best bet: Based on all the evidence contradicting the use of chemotherapy codes for Xolair, expect CPT to install 90772 as the only proper Xolair injection code very soon. "Coders should know that there may be 'official' instruction handed down soon, but that at this point this is a recommendation," O'Neil explains.

When the official word on 90772 goes public, coders are likely to find the official clarification:

• via an article in CPT Assistant,

• within revised language in the 2007 CPT manual or

• in subsequent revisions to the Medical Carriers Manual.

No Physician Presence, No 90772

Remember that the patient must receive the Xolair injection under the supervision of the pulmonologist in order to report 90772, explains Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia. If there is no direct physician supervision, CPT wants coders to report a level one evaluation and management (E/M) service.

For example, an established patient who has extrinsic asthma due to house dust sensitivity comes to the office for a 150 mg shot of Xolair.

The physician assistant (PA) administers the injection and sends the patient home. The physician was not in the suite during the encounter. Since there was no physician presence, you should:

• report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) for the encounter instead of 90772.

• attach ICD-9 code 493.00 to 99211 to prove medical necessity for the E/M visit.

• report J2357 x 30 for the Xolair supply.

Important Note: If you are reporting 99211 to Medicare under "incident-to" guidelines, the physician must be present in the office suite. If the service does not meet these guidelines, the PA should report the injection code (90772) under the independent billing guidelines.