Otolaryngology Coding Alert

Question: How should I code a Synagis injection? Commercial insurers keep denying the procedure. Should I appeal these decisions?


Utah Subscriber


Answer: Before you appeal the denial, check that you coded the procedure properly and that the procedure meets your private payer's requirements.

1. Verify that you coded the therapeutic injection with 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) and the supply with 90378 (Respiratory syncytial virus immune globulin [RSV-IgIM], for intramuscular use, 50 mg, each).
 
Synagis is an immune globulin (Ig) - not a vaccine. Therefore, you shouldn't have used a vaccine administration code for administering Synagis.

2. Make sure that you linked 90378 and 90782 to the baby's gestational period, such as 765.27 (Disorders relating to short gestation and low birthweight; weeks of gestation; 33-34 completed weeks of gestation). Because physicians normally give Synagis to infants with a history of prematurity (less than 35 weeks of gestational age), you should use prematurity as the diagnosis.

3. If you submitted the code accurately, you should check with the payer for any software-imposed frequency limits. For instance, Claim Check has an edit in place that incorrectly limits the number of units allowed per calendar year.

4. You should also find out if the payer has any additional filing requirements. Insurers may deny 90782 and 90378 if the procedure doesn't meet certain payer-specific criteria, such as:
  treatment must occur during the respiratory syncytial virus (RSV) season, Oct. 1-April 30
  you administer a total of six doses (a seventh dose may require separate preapproval from the insurer). Information for Reader Questions and You Be the Coder was provided by a number of coding experts, including Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.; Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.