Practice Management Alert

Payers Say Xolair Shots Are Not Chemotherapy

Be on the lookout for some official guidance on reporting encounters in which your physician injects a patient with Xolair.

When reporting Xolair (aka omalizumab) shots, use standard injection codes, not chemotherapy codes, CPT's Drug Infusion Workgroup recommends.

The workgroup recently met to discuss the application of the injection codes, but no official word has been handed down yet, says Vicky O-Neil, CPC, CCS-P, president of The Hazlett Group in St. Louis. Still, you should get used to injection codes for Xolair, experts say, because it is difficult to justify the higher-paying chemotherapy code when injecting Xolair.

Best bet: Follow this advice when reporting Xolair injections for your patients--and wait for official word soon from CPT.

Asthma Patients Get Xolair Most Often

Xolair is a monoclonal antibody the physician injects to treat asthma. When your office nurse injects the substance under physician supervision, you should always report 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for the service, says a recent Cigna Government Services release.

Example: An established patient with extrinsic asthma reports for a Xolair injection and an asthma evaluation. Your doctor sees the patient, and then the nurse administers 300 mg of Xolair by injection into the patient and sends him home. On the claim, you should:

- report 90772 for the Xolair injection.

- report J2357 (Injection, omalizumab, 5 mg) x 60 for the supply of Xolair.

- report the appropriate evaluation and management (E/M) level from 99211-99215 for the office visit.

- append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to show that the E/M was separate from the injection.

- link ICD-9 code 493.00 (Extrinsic asthma; unspecified) to 90772, J2357 and the E/M code to indicate the medical necessity for the office visit and the Xolair injection.

You must also back your Xolair injection claims with strong documentation. Check out these documentation requirements for Xolair injections, from Cigna's North Carolina Local Coverage Determination (LCD):

- -Office records must clearly document the reason and frequency for the drug (Xolair) use.-

- -The documentation must reflect the dose administered, the current weight of the beneficiary, and the initial IgE level.-

- -This information and an appropriate history and physical examination must be available if requested by the carrier to determine coverage.-

Not only has Cigna instructed providers to use 90772 for Xolair shots, but it has gone out of its way to discourage the use of 96401 (Chemotherapy administration, subcutaneous or intramuscular; nonhormonal anti-neoplastic) for Xolair injections. The Cigna release states, -it would be incorrect to bill for administration of Xolair under 96401.-

Why? -Xolair is not an anti-neoplastic, as is required in this code,- Cigna says. Further, the CPT Manual 2006/Professional Edition says, -Report 90772 for nonanti-neoplastic hormonal therapy injections- and -Report 96401 for anti-neoplastic nonhormonal injection therapy.-

Take the safe payout: The temptation to report 96401 is strong, since it pays better than 90772. On average, 90772 pays $20 a shot, while 96401 pays about $56 a shot, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

But based on the published evidence contradicting the use of chemotherapy codes for Xolair, even though it is a monoclonal antibody, expect CPT to install 90772 as the only proper Xolair injection code very soon. Payers that accept 96401 for Xolair shots today may not have the same policy in a few months, depending on what action CPT takes.