Wiki Coding for Xolair Administration

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lmyers

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We have an allergist that is using 96401 to bill for the administration of Xolair with the thinking that it is a chemotherapy-type drug. He is getting paid for it at present, but I am concerned that he'll be subject to recoupment under review. Is anyone else using 96401? Our curent recomendation is to use 90772 with modifier 76 for repeat injections. I have also read on this forum that others bill 90772-59 since the injections are done at multiple sites. Also, are others billing for the preparation of the therapy 95144?
 
xolair

lmyers said:
We have an allergist that is using 96401 to bill for the administration of Xolair with the thinking that it is a chemotherapy-type drug. He is getting paid for it at present, but I am concerned that he'll be subject to recoupment under review. Is anyone else using 96401? Our curent recomendation is to use 90772 with modifier 76 for repeat injections. I have also read on this forum that others bill 90772-59 since the injections are done at multiple sites. Also, are others billing for the preparation of the therapy 95144?
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I just ran across this the other day also, I asked them why they were using the 96401 instead of the 90772 and they said they had been told they could do that (they being a pulmonary office) at a seminar/teleconference. I am still searching for the documentation for this. I have asked the office for this document but they haven't come through yet. I'm interested to hear from others also.
 
Cigna Gov- *Xolair (Omalizumab) is a monoclonal antibody given as a subcutaneous injection for the treatment of asthma. Based on the route of administration, the administration of this code should be billed using CPT code 90772, Therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular. It would be incorrect to bill for administration of Xolair under CPT code 96401, Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic” as Xolair is not an anti-neoplastic as is required in this code.

FL MCR-Because Xolair is a monoclonal antibody, the use of CPT code 96401 is permitted.

This is where I'm getting hung...I'll take a look again from the beginning. ;)
 
Rebecca - I see what you are saying, but the Cigna article does state on the first page "Chemotherapy administration codes will apply to...substances such as monoclonal antibody agents and other biologic response modifiers." So is Cigna Gov contradicting itself? (Wouldn't be a first for a MAC or FI)...
Lisa
 
You are sooo right, Lisa...I can ask the same question 3 times and receive 3 different answers. I think I'll email this question directly to them for confirmation. This way...I'll have an answer from them, on paper, in case I have to "go to bat". It typically takes 4wks to receive an answer. **Fingers Crossed**

I found a Q/A on another link

http://www.cignagovernmentservices.com/partb/help/faqs/mr/06_06.html
 
So I went to my CPT Professional 2008. Page 424 under Chemotherapy Administration states "Chemotherapy adminstration codes 96401-96349 apply to...substances such as certain monoclonal antibdy agents...". Xolair is a monoclonal antibody agent. CPT seems clear on the topic. Given the risks of the drug and the overhead/nursing time, it is my opinion that 96401 is appropriate. Again, just my opinion...
Lisa
 
"Remember: While this information is provided by Empire Medicare, Part B carrier in New Jersey and New York, your local contractor may slightly vary the list. Make certain that you follow written guidance provided by your local payers when filing claims."

http://codinginstitute.com/sample/onc_sample.pdf

~See page 5~

Also...
30.5 - Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

Since my carrier requires 90772, I suppose my research is finally over. Great question lmyers.
 
xolair admin

I received the confirmation I needed to use the 96401 for Xolair. We use a product called Craneware and they keep up to date on all the medicare regs and such. They sent out this update today.

SPLIT DOSE INJECTIONS

There has been confusion as to the number of units to bill for injections that require the nurse to divide a high dosage of a single drug and administer it in more than one injection site. The FCSO article provides an example of correct billing for CPT® 96401 for the administration of the drug Xolair. The drug Xolair is administered subcutaneously. Due to the drugs viscosity, only 150mg can be given in one injection site. In some cases, up to four injection sites may be needed to give a complete dose. FCSO advises that when a “single dose” is divided among more than one injection site to limit injections to not more than 150mg per site, only one unit of 96401 should be reported. Using multiple syringes to deliver a single “split dose” does not constitute separate injections for billing purposes.

Action Needed
Because distinct differences may exist between local policies covering identical services, it is advisable to consult with your Medicare FI or A/B MAC to confirm its guidance on this particular issue.
 
96401

Soooo what about multiple sites during the same session? One in the right arm, one in the left. 96401 with a modifier 50?

Never mind.
 
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96401 vs 90772/96372 for Xolair

Has the AMA tackled this issue yet that anyone knows of? I've read all the articles from FCSO (Florida) and The Coding Institute, as well as the Cigna Gov't Part B that have been posted, and it seems nothing is definitive other than to check your local carrier. There has to be something more concrete than this. (Or there should be anyway, lol!)
Anyone find anything new? :confused:
 
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