A completed CMS-1500 form for administration of omalizumab (Xolair) requires four pieces. See if you can identify all four when coding this sample scenario.
Scenario: An established patient who has extrinsic asthma due to house-dust sensitivity comes to the office for administration of Xolair, a monoclonal antibody. A nurse administers 150 mg of Xolair by injection into the patient under direct physician supervision and sends him home. You should report:
- 493.00 (Extrinsic asthma; unspecified) to indicate the medical necessity for the Xolair injection
- 90772 (Therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular) in complying with the recommendations of the ATS and ACCP for the Xolair injection; or when permitted by payer, use 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic)
- J2357 (Injection, omalizumab, 5 mg) x 30 for the supply of Xolair. Don't forget documentation: You must back your Xolair injection claims with strong documentation, or you will likely receive rejections.
Check out these documentation requirements for Xolair injections, from Cigna's North Carolina local coverage determination (LCD):
- -Office records must clearly document the reason and frequency for the drug (Xolair) use.-
- -The documentation must reflect the dose administered, the current weight of the beneficiary, and the initial IgE level.-
- -Office records must also support the continued use of the drug.-
- -This information and an appropriate history and physical examination must be available if requested by the carrier to determine coverage.-