Pulmonology Coding Alert

Question: Can you clarify which injection code to use with Xolair administration and what the medical necessity requirements are for this drug?

New Hampshire Subscriber

Answer: When you code for Xolair administration, report 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular).

For patients who receive Xolair injections, most payers will want you to have the following documentation available (check your specific policy requirements):an explanation for the reason and frequency for the Xolair use; and a record that includes dose administered, the current weight of the beneficiary, and the patient's initial IgE level. Empire Medicare article number A46088, "Omalizumab (e.g., Xolair) -- Related to LCD L25820" says these diagnosis codes prove medical necessity for Xolair:

• 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

• are being treated with a long-acting beta 2-agonist (such as salmeterol or formoterol).

If the patient does not meet all of these parameters, many payers may not consider her eligible for Xolair therapy. However, individual policies may vary slightly, so check with your insurer on specific Xolair issues.