Administrating biologics – which code to use

The Advocacy Council regularly receives queries from members on how to correctly code specific scenarios. Recently we received a request for assistance from a practice regarding correct coding for the administration of Dupixent and Fasenra.

Both Dupixent and Fasenra are add-on biologic therapeutic agents to primary medications and both medications are delivered in prefilled syringes. Dupixent is approved for home administration, although the first dose is usually provided in the allergist’s office. Fasenra is always administered in the allergist’s office.

Dupixent can be administered in the office to patients who don’t want to give themselves the injection at home. However, clear documentation of the patient’s concerns about home administration is necessary. A pre-authorization may be helpful if audited, but it is probably not necessary.

The code for the administration of either of these drugs is CPT 96372. This code contains reimbursement for a nurse visit; no other E&M can be charged – if that is the only reason for the visit. If the provider spends time with the patient explaining the drug, how to use it and discussing any concerns the patient has, then an E&M visit can be billed. 

HCPCS code J0517 (1MG) is the code to bill for Fasenra.  HCPCS J3490 (unclassified drugs) or J3590 (unclassified biologics) are HCPCS codes you can use for Dupixent.

Patients should be seen regularly to verify continued effectiveness of the treatment.

Even though Dupixent and Fasenra are monoclonal antibodies, third-party payors may not reimburse if you use the chemotherapy administration code CPT 96401, as they may not agree either medication meets the criteria for this code:

From CPT: The highly complex infusion of chemotherapy or other drug or biologic agents requires physician or other qualified health care professional work and/or clinical staff monitoring well beyond that of therapeutic drug agents.

 It is best to check with them on acceptance of the code, and, if you are able to use it, document:

  • Observation time by a specialized nurse who understands and is trained:
    • In special considerations for preparation, dosage, or disposal.
    • To treat anaphylactic and chemotherapy reactions.
    • In all purposes of patient assessment, provision of consent, safety oversight and intra-service supervision of staff.

While coding for the administration of Xolair is not a new question, the Advocacy Council still recommends checking with your third-party-payers to determine which code - CPT 96372 or 96401 - they will accept for Xolair and obtain written direction.

Most carriers, including Medicare, require the use of CPT 96372 for the administration of Xolair, but may allow multiple units of the code. Some insurance carriers will accept the billing of CPT 96401, but will only allow one unit to be billed.

Advocacy Issue: 
Billing, Coding & Payments