Pulmonology Coding Alert

Question: I know there are articles that state you can use ‘96401’ for Xolair administration but there are other societies and payers who say that Xolair does not meet the requirements for the ‘96401’ and should be billed with 96372. Which one is correct?

Chicago Subscriber

Answer: If your physician office doesn’t incur the cost of the drug, the physician/practice will not be reimbursed for the supply of the drug. If your practice is incurring the cost of the drug, you will have to report the supply with the J-code, J2357 (Injection, omalizumab, 5 mg).  Report one unit of J2357 for every 5mg of drug administered. So, if 50 mg of Xolair is administered, you need to report J2357 x 10.

The administration of the drug does represent an expense to the physician (for the office, staff and equipment), and therefore, you can report it. There has been much controversy over the correct code to select for Xolair administration. Although categorized as a monoclonal antibody which would make you lean towards reporting 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic), most payers require you to report 96372 (Therapeutic, prophylactic, or diagnostic injection [specify the substance or drug]; subcutaneous or intra muscular) due to the fact that the use of Xolair is not anti-neoplastic in nature.

If you see the notes for 96401, it includes the instructions to use 96372 for non-antineoplastic hormonal therapy injections. Without specific instruction allowing the physician to bill 96401 for Xolair administration, the more appropriate code to report is 96732. Most payers who once allowed reporting of 96401 for Xolair administration have revised their guidelines to only allow 96372.  Please check with your payers for definitive guidance.

Coding Tip:  If multiple injections of Xolair were provided, report the first injection with 96372, and the following injections using 96372 with the modifier 76 (Repeat procedure or service by same physician) appended.