Pulmonology Coding Alert

When the pulmonologist (or a staff member) injects a patient with omalizumab (Xolair), you may wonder if you can code the encounter with a chemotherapy administration code. Although there's been no official guidance handed down on the matter, evidence from the coding world strongly suggests Xolair shots are not chemotherapy.

Here's why you can quash all thoughts of chemotherapy injection codes for this service, and how to code your Xolair injection encounters correctly every time.

CPT has not yet offered any definite ruling on coding Xolair injections, but it is clear that most pulmonology practices and societies recommend using standard injection codes for Xolair. That's what CPT's Drug Infusion Workgroup recommended during a 2007 meeting, and it's what Cheryl Klarkowski, RHIT, CPC, does on Xolair claims.

Administration coding: When you code for the Xolair administration, report 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular), not 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal, anti-neoplastic), says Klarkowski, coding specialist at Baycare Health Systems in Green Bay, Wis.

"It would be incorrect to bill for administration of Xolair with 96401, as Xolair is not an anti-neoplastic, which is required for this code," says Cindy Parman, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders (AAPC) National Advisory Board.

Cigna Government Service's August 2006 Part B Medicare update offers this guidance: "Chemotherapy administration codes will apply to parenteral administration of non-radionuclide anti-neoplastic drugs and also anti-neoplastic agents provided for the treatment of non-cancer diagnoses (e.g., cyclophosphamide for autoimmune conditions), or to substances such as monoclonal antibody agents and other biologic response modifiers."

If the drug you are administering does not fit Cigna's description, you cannot use a chemotherapy injection code. Xolair does not appear to meet this description.

Note: Despite evidence strongly suggesting Xolair is not a chemotherapy drug, a few payers might still want you to use 96401 for Xolair injections. So be sure of the payer's preference before coding Xolair injections.

Your pulmonologist's staff will administer Xolair for patients with asthma, though the specific type of asthma may vary, Klarkowski says.

According to Empire Medicare article number A46088, "Omalizumab (e.g., Xolair) -- Related to LCD L25820," the only diagnosis codes that prove medical necessity for Xolair are:

• 493.00 -- Extrinsic asthma; unspecified

• 493.10 -- Intrinsic asthma; unspecified

• 493.20 -- Chronic obstructive asthma; unspecified

• 493.90 -- Asthma, unspecified.

You'll also have to be sure the patient meets other medical-necessity requirements for Xolair therapy. According to BlueCross BlueShield of Tennessee's Medical Policy Manual, Xolair is considered medically appropriate for individuals who:

• are 12 years of age or older,

• have a positive skin test to at least one perennial aeroallergen (for instance, prick/puncture test, intracutaneous test) or in vitro reactivity to a perennial aeroallergen,

• have IgE levels greater than or equal to 30 and less than or equal to 700 IU/mL,

• have inadequately controlled symptoms with the maximum dose of inhaled corticosteroids, and

• are being treated with a long-acting beta 2-agonist (such as Serevent, Advair).

If the patient does not meet all of these parameters, BCBS-Tennessee does not consider her eligible for Xolair therapy. However, individual policies may vary slightly, so check with your insurer to see what types of patients it considers eligible for Xolair.

(For more information on determining medical necessity for Xolair injections, see "Look to Tree for Medical Necessity Knowledge" on page 35.)

Klarkowski offers this example: An established patient with atopic asthma reports to the pulmonologist for a scheduled Xolair injection session. Under direct physician supervision, the nurse practitioner gives the patient three separate injections of Xolair (each shot is 50 mg).

On the claim, you would report the following:

• 90772 for the first Xolair injection

• 90772 appended with modifier 76 (Repeat procedure or service by same physician) for the second injection

• 90772-76 for the third injection

• 493.00 (Extrinsic asthma; unspecified) linked to all the injection codes for the patient's condition

• J2357 (Injection, omalizumab, 5 mg) x 30 for the supply of Xolair.

Document IgE Level for Records

If you don't have solid documentation to back your Xolair injection claims, you could be staring at a claim rejection. For patients who receive Xolair injections, most payers will want you to have the following documentation available (check specific policy requirements):

• an explanation for the reason and frequency for the Xolair use

• a record that includes the dose administered, the current weight of the beneficiary, and the patient's initial IgE level.

Remember that to report 90772 for Xolair injections, the pulmonologist must either perform the injection or supervise it personally. If the nurse practitioner or other staff performs the injection without physician supervision, CPT suggests that you report a level-one E/M instead (99211).

Beware: Do not report this for Medicare patients, because 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) represents an incident-to service, which also requires direct physician supervision (in the office suite) at the time of service.

When the NP injects a patient with Xolair without physician supervision, report 90772 for the injection under the NP's National Provider Identifier (NPI).