Pediatric Coding Alert

Question: Insurers keep denying 90378 with 765.10. How can I obtain Synagis payment? Texas Subscriber Answer: You're going to have to link the immune globulin (90378, Respiratory syncytial virus immune globulin [RSV-IgIM], for intramuscular use, 50 mg, each) (generic palivizumab, registered name Synagis) to a different ICD-9 code. The diagnosis (765.10, Disorders relating to other preterm infants unspecified weight) you are using describes the premature infant's weight. But the American Academy of Pediatrics (AAP) RSV-IgIM Prematurity guidelines are based on gestation age, not weight. Therefore, you should instead assign an ICD-9 code from the 765.2x (Weeks of gestation) series to represent the infant's gestation. Coverage depends on the infant's estimated gestational age at the start of RSV season (Oct. 1). Following AAP guidelines, diagnoses that insurers typically accept for 90378 include: * Check with your insurer for the number of required factors. Some may require only one anatomical problem. For instance, Texas Medicaid and CSHCN Services Programs will preauthorize palivizumab for beneficiaries younger than 6 months when risk factor of severe neuromuscular disease or significant congenital anomalies are present or child has two social risk factors. -- Answers to You Be the Coder and Reader Questions provided/reviewed by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City; and Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville.