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Coding for Xolair Administration

  1. Default Coding for Xolair Administration
    Medical Coding Books
    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?

  2. #2
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    We only bill J2357 xdose and 90772. We dont add any modifiers. Havent had any problems.

  3. #3
    Default xolair
    Quote Originally Posted by lmyers View Post
    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?

    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.

  4. #4
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    Food for thought...

    http://www.floridamedicare.com/Part_...nes/135608.asp

    http://www.cignagovernmentservices.c.../Cope4500.html

    Looks like these two sites contradict each other....??
    Last edited by RebeccaWoodward*; 11-05-2008 at 03:19 PM.

  5. #5
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    Quote Originally Posted by rebeccawoodward View Post
    Food for thought...

    http://www.floridamedicare.com/Part_...nes/135608.asp

    http://www.cignagovernmentservices.c.../Cope4500.html

    Looks like these two sites contradict each other....??
    Actually, I think they both support the use of 96401 since Xolair is a monoclonal antibody. Very interesting. What do others think please?
    Lisa Bledsoe, CPC, CPMA

  6. #6
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    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.

  7. #7
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    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
    Lisa Bledsoe, CPC, CPMA

  8. #8
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    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.c.../mr/06_06.html

  9. #9
    Default xolair admin
    This is very confusing. I also found this site that recommends 90772 and not 96401 from the coding institute.
    http://codinginstitute.com/articles/...ng_xolair.html
    I'm still searching!

  10. #10
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    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
    Lisa Bledsoe, CPC, CPMA

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