Pulmonology Coding Alert

Hint: Don’t forget administration code when you report Xolair injections.

When you think about your most-billed codes, your mind probably goes to E/M services and spirometry, but the service that ranked sixth among pulmonologists’ most-reported codes last year was J2357, according to Medicare utilization data.

Unforutnatley, J2357 (Injection, omalizumab, 5 mg) is not the most straightforward code to report – it requires you to pair it with not only the right ICD-10 code, but also an appropriate administration code.

Background:  Xolair (Omalizumab) is a drug prescribed for adolescents and adults who have been diagnosed with moderate to severe persistent allergic asthma, in whom inhaled corticosteroids and other treatments have not been adequate enough to control the symptoms. Check out the following tips to find out how you should report these services.

Tip 1: Medical Necessity Is King When Billing Xolair

Before billing for Xolair injections, make sure you have fulfilled the coverage conditions for the service. For instance, in a policy last updated on Sept. 1 of this year, United Healthcare stipulates the circumstances under which Xolair injections are covered, including the following, among others:

• The patient must have a confirmed diagnosis of moderate to severe persistent uncontrolled or inadequately controlled 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 inhaled corticosteroid or other treatment.
• An immunologist or pulmonologist prescribes the Xolair treatment.

Tip 2: Master the Documentation Requirements

Each payer lists its own documentation requirements for this service. For example, Part B MAC First Coast Service Options states that the following must be met for payment:

• 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.

Tip 3: Remember the Right Diagnoses

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

• J44.9 (Chronic obstructive pulmonary disease, unspecified),
• J45.40 (Moderate persistent asthma, uncomplicated)
• J45.50 (Severe persistent asthma, uncomplicated)
• L50.1 (Idiopathic urticaria)
• L50.6 (Contact urticaria)
• L50.8 (Other urticaria)

You should check your LCD guidelines for exact codes before you perform the service to ensure that your patient’s diagnosis covered by the payer’s policy.

Tip 4: Pinpoint An Administration Code

Unless there is a specific instruction for the physician to report a separate code for Xolair administration, 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) is typically the appropriate code to use for this service.

Problem:  Although omalizumab is classified as a monoclonal antibody, which might make you lean toward reporting 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic), most payers actually instruct you to report 96372 instead.

Tip 5: Know the Dosage Rules

When reporting J2357, keep in mind that you’ll report one unit per 5 mg administered, so make sure you specifically check the number of units on all of your claims. Most physicians will use at least 150 mg, so you’d have at least 30 units of J2357 on the claim. Most payers have a maximum number of units allowed, says Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. “For example, UHC (United Healthcare) allows a maximum dosage of 375 mg, or 90 units (5mg per unit) to be reported.”

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. In those cases, you could only report the administration code.

Tip 6: Avoid 99211 With Xolair Claims

Some practices tend to tack 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) on to each Xolair administration, but that’s not necessarily a smart idea.

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 payment for the code. Therefore, do not report this code for Xolair administration. To prevent inappropriate reporting, NCCI bundles 99211 into 96372, and no modifier can be used to unbundle the service, Pohlig says.

Tip 7: Check Out a Case Scenario for Correct Implementation

Unsure of how to put all the elements together? Check out the following example.

Scenario: A patient with severe, uncontrolled asthma presents to your office. A nurse injects him with 150 mg of Xolair under direct physician supervision and the patient returns home subsequently. You may therefore report:

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

Always remember that injections require direct supervision of the staff member who is performing the administration, so be sure that a physician or advanced practice provider is in the office suite at the time of service.