Pulmonology Coding Alert

Question: An established patient with intrinsic asthma comes to the office for an evaluation and a Xolair injection. The pulmonologist checks the patient's condition during the course of a level-two E/M service. The nurse then injects 200 mg of Xolair, with the physician present, and sends the patient home. How should we code this scenario?

Answer: You will be able to report two CPT codes in this scenario: one for the injection and another for the E/M, because it was separate from the injection.

• 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for the shot
• J2357 (Injection, omalizumab, 5 mg) x 40 for the Xolair supply
• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key elements: a problem-focused history; a problem-focused examination; straightforward medical decision-making) for the E/M
• modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99212 to show that the E/M was separate from the injection
• ICD-9 code 493.10 (Intrinsic asthma; unspecified) linked to 90772 and 99212 to prove medical necessity for both services.

Documentation alert: Support your Xolair claims with the appropriate documentation or you're likely to receive rejections. Many insurers have specific documentation requirements you'll have to meet.

• "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."

Also: Remember that the patient must receive the Xolair injection under the supervision of the pulmonologist in order to report 90772. Without physician supervision, you'll have to shelve 90772 and report the appropriate E//M code instead.

Reminder: Some contractors specify 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic) for Xolair administration. In the absence of such a policy, American College of Chest Physicians (ACCP) guidelines encourage physicians to report 90772 for Xolair administration, since this best represents the time and effort of the pulmonologist's service.