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 who received a denial for the administration of Xolair.
Q: My claim for administering Xolair – using CPT 96372 – was denied. What’s the correct code to use?
A: Medicare requires the use of CPT code 96372 –Therapeutic, prophylactic, or diagnostic injection, specify substance or drug; subcutaneous or intramuscular for the administration of biologics. Local Coverage Determinations specifically name this as the correct code when billing Medicare (or insurance carriers that follow Medicare rules) for Xolair. Medicare does allow for multiple units/injections using this code.
Because the practice didn’t buy the Xolair, they didn’t list it on the claim form and the claim was denied. Correct coding would be 96372 X 2 units (or use two claim lines) and J2357 X 1 unit (if you don’t do buy and bill, just use a nominal amount e.g., $0.01)
It is also important to have the proper associated diagnosis.
Third-party payers MAY allow use of CPT code 96401 – Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic for administration of a biologic. You may want to receive written pre-approval from the carrier before using this code on a claim. Also verify whether the carrier’s approval applies to all its beneficiaries or only this individual patient.
Do you have a coding conundrum of your own? Share it with us!
And check out our coding toolkit and Insider article Administering biologics – which code to use for more helpful resources.
