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Xolair Administration

Tina Posted Tue 10th of September, 2013 16:27:13 PM

I know there are articles that state you can use '96401' for Xolair administration but there are other societies and payers who say that Xolair does not meet the requirements for the '96401' and should be billed with 96372. Which one is correct?

SuperCoder Answered Tue 10th of September, 2013 17:58:29 PM

Here is a exerpt from SuperCoder that I found - regarding administering the Xolair (published Aug 2010, Pulmonology Coding Alert):

"Since the physician office doesn't incur the cost of the drug, the physician/practice should not be reimbursed for this. On the other hand, the administration of the drug does represent an expense to the physicain (for the office, ataff and equipment), and therefore, you can report it.

Red Flag
There has been much controversy over the correct code to select for Xolair administration. Athough catagorized as monoclonal antibody (which would lend toward reporting 96401. Chemotherapy administration, subcutaneous or intramuscular; non-0hormal andi-neoplastic)., most payers require reporting 96372 (Therapeutic, prophylactic, or diagnostic injection- specify the substance or drug - ; subcutaneous or intra muscular)due to the fact that the use of Xolair isn not anti-neoplasticin nature.Without specific instruction allowing the physician to bill 96401 for Xolair administration, the more appropriate code to report is 96732"

Tina Posted Fri 25th of October, 2013 09:48:15 AM

Do you know if there is anything out there from AMA or CMS on this issue? Also, since Xolair can only be given in 150mg doses, what do you do if the dose requires 2 or more injections? Do you bill for each injection or do you just bill once since it is one drug but had to for safety reasons be given in multiple doses??

SuperCoder Answered Fri 25th of October, 2013 15:00:35 PM

Please check the Page3 of the following link :

Medicare does not have a National Coverage Determination (NCD) for omalizumab (Xolair). In
general, Medicare covers outpatient (Part B) drugs that are furnished “incident to” a physician’s
service provided that the drugs are not usually self-administered by the patients who take them.
See the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals at
Local Coverage Determinations (LCDs) exist for Omalizumab (Xolair) and compliance with these
policies is required where applicable.

You can use 96372 in this case if another injection also needs to be given (dosage requirment) then use mod 59 with second 96372.

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