Pulmonology Coding Alert

CPT moves to make 90772 the only choice for these shots

After years of confusion and conflicting information on which code set to choose from, there will finally be some official guidance coming on reporting encounters in which a pulmonologist's staff injects a patient with omalizumab (Xolair).

The verdict: When reporting Xolair shots, use standard injection codes, not chemotherapy administration codes, recommends CPT's Drug Infusion Workgroup.

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, CSS-P, president of The Hazlett Group in St. Louis. Still, pulmonology coders 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 staff injects the substance, you should always report 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for the shot, according to a Cigna Government Services release.

Example: An established patient with atopic asthma comes to the office for an asthma evaluation and for Xolair administration. The pulmonologist sees the patient; then the nurse administers 300mg 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 the E/M was separate from the injection.

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

Don't forget documentation: You must back your Xolair injection claims with strong documentation, or you're likely to receive rejections.

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."

• "Office records must also support the continued use of the drug."

• "This information and an appropriate history and physical examination must be available if requested by the carrier to determine coverage." Shelve Chemo Codes For Xolair Admin Not only has Cigna instructed providers to use 90772 for Xolair shots, it has also gone out of its [...]