Use of 96401 for Xolair Injections

jmwinter

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It has been presented to my practice by the Xolair drug reps, that we can bill 96401 for Xolair injections due to the fact that Xolair is a monoclonal antibody. Even thought 96401 is listed under Chemotherapy Admin. CPT has changed the introductory language to the chemotherapy section. Does this allow the use of 96401 for Xolair in use for asthma patients? I am looking for Documentation Guidelines that would support this coding option.

I would appreciate any assistance in finding documented guidelines for this issue.
 
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Coding Xolair

I believe everything you need can be found at this link

http://www.chestjournal.org/cgi/reprint/129/2/466.pdf

According to them:

"The actual current procedural terminology (CPT) code used for the administration of the omalizumab is generally 90772 and can be billed for each injection administered. Discussion among coding specialists has also indicated that certain insurance carriers will reimburse for the more complex code, 96401, generally paid at a higher level, but usually reserved for chemotherapy administration via the subcutaneous route. Of course, if an office visit is
also performed on the day of the injection, then that specific evaluation and management code should also be billed, commensurate with the level of
complexity and with the appropriate modifier ( 25)."

Hope this helps
 

Erica1217

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Here's another good resource that includes some excellent sample appeal letters: http://www.healthyairways.com/documents/xolair_06_03_04.pdf

I don't think you really need any other documentation guidelines. It states right in the CPT Manual that the chemo codes can be used for monoclonal anitibodies.

I would check with your payors, though, to see if they have a policy because many do.

For example, here's Aetna's and they want 95115 -
http://www.aetna.com/cpb/medical/data/600_699/0670.html

Here's United Healthcare and they want 90769 or 90772 -
https://www.unitedhealthcareonline.com/b2c/cmaIndexResult.do?channelId=016228193392b010VgnVCM100000c520720a____&htmlFilePath=/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/MedicalPolicies/Xolair.htm

We used to bill 95115 w/ a 22 modifier. Then we switched to 96401. What a pain it was.

Good Luck!!!

:) Erica
 
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