Pulmonology Coding Alert

Know the differences between 90782 and G0355

To record accurately the additional drug prep time for Omalizumab (brand name Xolair) injections, you shouldn't use 99211, 95115 or 95117, or your claims may be rejected. Follow these expert tips to find out exactly which codes you need.
 
CMS Allows G0355 for Monoclonal Antibodies

If your pulmonologist is administering monoclonal antibodies injections to Medicare patients, you should report G0355 (Chemotherapy administration, subcutaneous or intramuscular non-hormonal antineoplastic). Since Xolair is an IgE blocker or inhibitor that is classified as a monoclonal antibody, G0355 is the appropriate code to report to Medicare for Xolair injections.
 
"CMS has made it very clear that G0355 may be used to report injections of non-chemotherapy substances and that a cancer diagnosis is not needed," says Vicky O'Neil, CPC, CCS-P, coding and compliance educator in St. Louis, Mo. "Specifically, they say that this code may be used to report injections of monoclonal antibodies, which Xolair is."

Private Carriers Prefer 90782

If you report 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) for Xolair injections, you'll stand a better chance of getting reimbursement from private carriers.

"The G codes are only for Medicare patients," says Janette Stauffer, BS, RHIT, CPC, coding services educator with the Wichita Clinic, in Kansas. Most other payers do not recognize G codes.

Tip: If your pulmonologist gives multiple injections on the same day, attach modifier 76 (Repeat procedure by same physician) to 90782 to specify that the physician provided multiple injections. For example, when the physician gives more than one Xolair injection in one day to a patient who requires dosing by weight, report 90782-76.

"Since the G codes are recognized only by our local Medicare and BC/BS carrier, we use 90782 for all other payers with modifier 76 if multiple injections were used on the same date of service," says Monica Horner, billing manager and consultant for a large pulmonary practice in Pittsburgh.
 
Note: Be sure to check with your individual payers on how they prefer you code for Xolair. "Keep in mind that the use of modifiers and CPT codes is payer-specific and their use should be verified," Horner says.

Avoid 95115 and 95117 for Xolair

You may be tempted to report 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or 95117 (... two or more injections), but those codes don't accurately describe Xolair injections. 

Watch out: Although 95115's and 95117's code descriptions can be confused with the type of service Xolair injections provide, you should always use the code that best represents the service provided. Codes 95115 and 95117 specify allergy antigen immunotherapy. Since Xolair is a medication consisting of antibodies, not allergens, and is not considered an antigen immunotherapy, you shouldn't report these codes in this case.

99211 Isn't a Viable Addition

Since Xolair injection services require more dose preparation than most average injection therapies, you might consider 99211-25 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician; significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to be an additional code to report to capture additional revenue for the extra time. Don't fall into this trap.

Rationale: The problem with using 99211 for Xolair injections is that payers already include dose prep and routine patient assessment and monitoring in the relative value units, or physician work. (For more on 99211, see the articles "Reporting Pneumo Vaccines? Keep 99211 Separate" and "A Quick Check of 99211 Requirements Will Guarantee Payment" later in this issue.)

Don't Use J3490 or J3590 Anymore

You no longer need to use the unclassified-drug codes J3490 (Unclassified drugs) or J3590 (Unclassified biologics) to report Xolair injections. The 2005 HCPCS code for Xolair is J2357 (Injection, omalizumab, 5 mg). This code is per 5 mg, so make sure you specifically check the number of units on all of your claims, O'Neil says. "The threshold for Xolair patients is 150 mg, so you should always have at least 30 units of J2357 on the claim," she adds.

Note: If the patient, not your office, supplied the medication for the injection, you shouldn't report J2357. Physicians are only able to bill for drugs and supplies if they incur direct cost by providing them.