Pulmonology Coding Alert

Know why you should choose 96372 above the rest.

Are you too stuck in a dilemma to choose the correct code for Xolair administration? With time, there have been changes in what payers want, and different payers have different guidelines about codes eligible for reimbursement. Read on to explore your options, and how to make the most of your Xolair services.

Background: Xolair (Omalizumab) is a drug prescribed for adolescents (who are 12 years or older),and adults, diagnosed with moderate to severe persistent allergic asthma, in whom inhaled corticosteroids and other treatments have not been adequate enough to control the symptoms.

Comply With Medical Necessity before Billing Xolair

Before billing for Xolair injections, make sure you have fulfilled the coverage conditions for the service. For example, United Healthcare^® stipulates that Xolair injections will be covered only if all the following conditions are met:

• The patient must be 12 years or older;
• The patient should have a confirmed diagnosis of moderate to severe persistent uncontrolled asthma;
• The baseline serum total IgE level should be 30 IU/mL or more, prior to Xolair treatment and ≤ 1500 IU/mL;
• The patient demonstrates an in vitro reactivity to an aeroallergen all year round, or a positive skin test.
• Documented inadequacy of at least 3 months of treatment with inhaled corticosteroid or other treatment.
• An immunologist or pulmonologist prescribes the Xolair treatment.

Moreover, if the patient has already been on Xolair therapy for 16 weeks or more, without showing any improvement, then further use of Xolair is deemed to be medically unnecessary.

Master the Documentation Requirements

• The patient’s history and physical must provide adequate justification for the diagnosis of moderate to severe persistent asthma.
• Mention specifically that the patient has been on inhaled corticosteroids or other treatments in the recent past, and that the patient’s symptoms were not controlled with those treatments.
• Basic data such as patient’s weight;
• Document that the patient demonstrates an in vitro reactivity to an aeroallergen all year round, or a positive skin test.

The right codes: Make sure that you support the Xolair administration with allowed diagnosis codes for smooth reimbursement. Some examples of acceptable ICD-10 codes are:

• J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation),
• J44.9 (Chronic obstructive pulmonary disease, unspecified),
• J45.40 (Moderate persistent asthma, uncomplicated)
• J45.41 (Moderate persistent asthma with [acute] exacerbation)
• J45.42 (Moderate persistent asthma with status asthmaticus)
• J45.50 (Severe persistent asthma, uncomplicated)
• J45.51 (Severe persistent asthma with [acute] exacerbation)
• J45.52 (Severe persistent asthma with status asthmaticus).

You should check your LCD guidelines for exact codes.

Choose well from 96401 and 96372

Unless there is a specific instruction for the physician to report 96401 for Xolair administration, 96732 is the more appropriate code to report. Most payers have revised their guidelines to only allow 96372, including those who once accepted 96401 for Xolair administration.

Problem: Although Omalizumab is classified as a monoclonal antibody which might make you incline towards reporting 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic), most payers actually allow you to report 96372 (Therapeutic, prophylactic, or diagnostic injection [specify the substance or drug]; subcutaneous or intramuscular). This could be due to the fact that the Xolair is not used for anticancer treatments. Moreover, if you dig into the notes for 96401, you would come across instructions to use 96372 for hormonal therapy injections, which are non-antineoplastic in nature.

Extra tip: If multiple injections of Xolair are provided, report the first injection with 96372, and the following injections using 96372 with a suitable modifier. Private payers may accept modifier 76 (Repeat procedure or service by same physician) appended, if they do not follow Medicare guidelines. However, Medicare allows modifier 59 (Distinct procedural service) and the X modifiers, but does not recognize modifier 76 with this code.

Know the Drug Codes That Matter: J2357

The code G0355 (Chemotherapy administration), obsolete now, was used to report injections such as Xolair of non-chemotherapy monoclonal antibody substances as well until 2005. “It was deleted in 2005 and was replaced with 96401 in 2006,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Medicare also recognizes the supply of the drug with HCPCS code J2357 (Injection, omalizumab, 5 mg). This code is per 5 mg, so make sure you specifically check the number of units on all of your claims. The threshold for Xolair patients is 150 mg, so you should always have at least 30 units of J2357 on the claim.

Note: If the patient, not your office, supplied the medication for the injection, you shouldn’t report J2357. Physicians are only able to bill for drugs and supplies if they incur direct cost by providing them. “You would only be able to report the appropriate administration code,” says Pohlig.

Avoid 99211, 95115 and 95117 for Xolair

In case you are thinking of using 99211-25 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional; Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) as additional codes to report to capture additional revenue for the extra time, your efforts may not bear fruit.

Here’s why: Although Xolair injection services require more dose preparation than most average injection therapies, the problem with using 99211 for Xolair injections is that payers already include dose prep and routine patient assessment and monitoring in the relative value units, or physician work.

Although the code descriptions of 95115 and 95117 may tend to confuse you, if you read carefully- codes 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) and 95117 (... two or more injections) refer to allergy antigen immunotherapy. Since Xolair consists of antibodies rather than allergens, it does not come under antigen immunotherapy. Therefore, do not report these codes for Xolair administration.

Check Out a Case Scenario for Correct Implementation

Completing a CMS-1500 form for Xolair administration needs you to be aware of four components. See if you can identify all four when coding this sample scenario.

Scenario: A patient with known extrinsic asthma, sensitive to house-dust, comes to the clinic. A nurse injects him with 150 mg of Xolair under direct physician supervision and the patient returns home subsequently. You may therefore report:

• 96372
• J45.40 to justify the medical necessity for the treatment
• J2357 x 30 units for the supply of Xolair

In this context, Pohlig adds that in order to ensure you are meeting all the guidelines for reporting Xolair services, be sure that following are always taken into consideration:

• Coverage
• Cost
• Coding
• Supervision

Without meeting the criteria for each of these considerations, billing for Xolair may not be appropriate.

In a nutshell: “Injections require direct supervision of the staff that is performing the administration,” says Pohlig. “This means that a physician or NPP must be in the office suite at the time of service. The individual providing supervision will be the name submitted in the claim.”

Turn to Your Payer for Exact Xolair Interpretation

Make sure you confirm with your individual payers the guidelines for reporting Xolair administration. Remember that the use of modifiers and CPT^® codes is payer-dependent.

As for Medicare, it does not have a national coverage for the Xolair administration and leaves it to local payers for their own rules.

Ref: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools and Resources/Policies and Protocols/Medical Policies/Drug Policies/Xolair_policy.pdf.