Pulmonology Coding Alert

Question: I had a Xolair administration case and wanted to use 96401 after going through some sources. However, some societies and payers reject it. Am I correct? Also, since Xolair can only be given in 150-mg doses, what do you do if the dose requires two or more injections? Do you bill for each injection or do you just bill once since it is one drug but had to for safety reasons be given in multiple doses?

Virginia Subscriber

Answer: No. Actually, Xolair administration has been a controversial procedure for coders and payers alike. As Xolairoromalizumab is a monoclonal antibody, and in the past seemed to qualify for code 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic).Chemotherapy administration code 96401 applies to administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of non-cancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as certain monoclonal antibody agents, and other biologic response modifiers. Therefore, most payers now reject claims based on the code because Xolair is not anti-neoplastic in nature and thus out of the purview of 96401; the descriptor clearly mentions that the drug should be “anti-neoplastic.”

Therefore, in your case, as there is no specific instruction from your pulmonologist that allows 96401, the more appropriate code to report is 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular).

For your second question, if another injection also needs to be given under individual dosage requirement or the dosage has to be divided into multiple infusions, then you may use 96732 and a second unit of 96732 with modifier 59. Just remember that there should be sufficient reasoning documented by the physician for warranting the dosage break-up.

Heads Up: Under normal logic, the payers should not reimburse the physician/practice for the administration of the drug because the physician office doesn’t pay the cost of the drug. On the other hand, he has to incur costs for the administration of the drug (for the office, staff and equipment), and therefore, you can report it.