AAAAI Coding Questions & Answers Asthma

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1 I have been doing some research on CPT vs for Xolair administration. Are you aware of any reading material on this subject that is available? We have been told to bill a chemo type of administration for Xolair. Can you tell me what codes would be acceptable? The only reading material would be the subsection heading instructions for the codes to understand what is required for support of the code. The also has subsection instructions. You may also want to read payer policies such as your Medicare MAC. There are two codes for injection of Xolair. The code for a monoclonal antibody is and the other code appropriate is I would like to know the difference between and I perform office based spirometry. I was told by our biller that to qualify for 94375, I would have to perform full PFTs in a hospital setting. Please clarify. My printout has both the inspiratory and expiratory loop. I can thus bill 94375? The and the do not require a hospital setting. The difference is in the measurement of the patient. One is inspiratory and one is expiratory. The results are usually both given as a result. The physician needs to comment on the one which is charged. Yes, as long as you comment on the So, for aerosol bronchodilation, is the medication included in the code or should be billing separately? You should charge for any medications you purchase. The does not include the cost of the medications. I have a claim for E&M plus multiple procedures done on the same day with CPT codes as follows: with modifier 25; 95004; with modifier 59; J7620 (nebulized Albuterol sulfate.083% 2.5 mg); G0436 smoking cessation 1. Here are my questions: Do I have the correct modifiers on the claim? Are there too many CPT codes on this claim? Do I run the chance of not being reimbursed for the most important CPT codes? Should albuterol dose be counted as only 1 unit? 2. I would like some clarification regarding when modifier 59 should be used and why it is not needed in this case. 1. You do not need the 59 modifier on the You can use 1 for the unit of Albuterol. Make sure you link in the first position your diagnoses codes appropriately. Otherwise, it looks good. 2. The 59 modifier is not required because the PFT does not bundling into the allergy testing in the Correct coding initiative. The 59 modifier is only required when you are indicating there are two separate services which usually are inclusive but because of the patient's condition, they should be both charged.

2 We are sometimes having denials involving code We have patients that will have an office visit then will get a Xolair or Depo Medrol injection at the same encounter and also pre-post spirometry, would adding the modifier 59 or XU to be correct? Another would be patient comes in for their allergy shots then may get their Xolair injections or Depo Medrol injection when ordered, would a modifier 59 or XU be added to or would a modifier XS be correct for a situation of and (steroid shot same visit). 1. No modifier would be required if you use the 25 modifier and are following CMS guidelines. 2. This is correct. You would place the XU on either the or the Or, I would use the Xu or the 59 modifier. I would not use the XS. Or would a modifier 25 added to an EM code with listed even with a be generally only necessary? I looked up our more common carriers and they seemed to be following the CMS guidelines/tables for NCCI edits, bundling. Examples: , 94060, (Xolair) +XU, or , 94060, (Steroid injection) with modifier or not? What would you recommend to be most common? , 94060, (Xolair) +XU, no modifier; Correct? with 96372(Xolair) with modifier XU or no? We were told by our in-house coding compliance dept. that we cannot code codes J45 with Allergic Rhinitis is this true? I do not see Allergic Rhinitis listed under the Excludes 1 list associated with. J45 codes include rhinitis. Does that mean we cannot code both rhinitis and asthma? The only asthma diagnosis code excluded with allergic rhinitis is J I would code the allergic rhinitis and the asthma codes for mild, moderate or severe. Only the J is excluded with allergic rhinitis. I am wondering because if we do not code rhinitis in addition to asthma, will that mess up things if the patient is on immunotherapy? And only coding asthma will not specify the allergens that affect the patient

3 I am inquiring about an ICD-10 code for occupational asthma. Is there a specific code for this diagnosis? In patients on Xolair for either chronic idiopathic urticaria or asthma, can you provide me with the following: ICD 10 for chronic idiopathic urticaria and allergic asthma? Injection fee for mixing up the Xolair (patient has already paid for the actual medication, as they have ordered Xolair from specialty pharmacy) and providing injection(s). What code would we use for 'Occupational ", (J45.988)? We billed CPT along with CPT 99215, CPT 94640, CPT J1100 and CPT CPT was denied by BCBS, reason "procedure not paid separately." Is this payable, or is a modifier needed? We billed CPT along with CPT 99215, CPT 94640, CPT J1100 and CPT CPT was denied by BCBS, reason "procedure not paid separately." Is this payable, or is a modifier needed? I am inquiring about an ICD-10 code for occupational asthma. Is there a specific code for this diagnosis? In patients on Xolair for either chronic idiopathic urticaria or asthma, can you provide me with the following: ICD 10 for chronic idiopathic urticaria and allergic asthma? Injection fee for mixing up the Xolair (patient has already paid for the actual medication, as they have ordered Xolair from specialty pharmacy) and providing injection(s). There isn't a specific excludes or includes for occupational asthma in the ICD-10CM J 45 category. Lung disease due to external agents (j60-j70) and miner's asthma (J60) are the closest to occupational asthma separate categories. Allergic asthma is now considered as inclusive in the new language for mild, moderate and severe. Persistent and intermittent is also part of the new terms for your asthma patients. Your physician(s) will need to make a determination regarding how your patients fit into this category. L50.1 is the code for idiopathic urticaria. The codes for the injections of Xolair are either or depending on your payers guidelines. Occupational asthma has not been assigned a specific code since the specific asthma codes are related to mild, moderate, severe, persistent and intermittent. Otherwise, you will need to use the not otherwise specified. The is payable separately but you will need to submit documentation to support your extra time in addition to the You would need at least 75 minutes face-to-face with the patient to support the first hour of prolong services, The is payable separately but you will need to submit documentation to support your extra time in addition to the You would need at least 75 minutes face-to-face with the patient to support the first hour of prolong services, There isn't a specific excludes or includes for occupational asthma in the ICD-10CM J 45 category. Lung disease due to external agents (j60-j70) and miner's asthma (J60) are the closest to occupational asthma separate categories. Allergic asthma is now considered as inclusive in the new language for mild, moderate and severe. Persistent and intermittent is also part of the new terms for your asthma patients. Your physician(s) will need to make a determination regarding how your patients fit into this category. L50.1 is the code for idiopathic urticaria. The codes for the injections of Xolair are either or depending on your payers guidelines.

4 1. What code would we use for 'Occupational ", (J45.988)? Occupational asthma has not been assigned a specific code since the specific asthma codes are related to mild, moderate, severe, persistent and intermittent. Otherwise, you will need to use the not otherwise specified. What does "allergy status to ----" mean? In particular, what does "status" mean? Status - the patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. History - indicates the patient no longer has the condition. We frequently perform bronchospasm evaluations using CPT code During the process, we also code for We are getting denied for the Is this industry standard or specific for certain carriers in the U.S.? We are getting denials on CPT code Do you have any suggestions? Are there better CPT codes to use in its place? We are actually not using this code for oral challenges; we are billing thermal challenges (ice cube test, for example) with CPT I have the following question about billing vs : If a patient receives 2 or 3 immunotherapy injections, instead of using the code, can I use CPT and specify 2 units (or 3 units for 3 injections)? Does the reimbursement amount change depending on which code is used? 2) Is the correct code for Xolair injections? If a patient gets 2 Xolair injections per visit, how should this be coded? Is CPT J2357 code needed for Xolair as well? What does "allergy status to ----" mean? In particular, what does "status" mean? The MDI instruction is included in CPT 94060, if you are instructing the patient on how to use it appropriately for acceptable pre and post spirometry. If you are instructing the patient regarding a different one from the one used in the pre and post spirometry, you may add a 59 modifier to the 94664, and it should go past edits from the insurance companies. "There isn't a code any longer for If you are performing oral challenges, you should be using the and the " The CPT book has written the codes for one injection and for two or more. You would not be able to increase the units for and receive higher reimbursement. The is an appropriate code for Xolair, as long as the payer recognizes the code as appropriate for Xolair. If you provide 2 Xolair injections, you can either increase the units or use a 76 on a second line item of as a repeat procedure. J 2357 may need to be coded to provide information regarding what type of injection you are providing. Status - the patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. History - indicates the patient no longer has the condition. The J45 asthma code now include allergic rhinitis with asthma. Does this mean you cannot code for asthma and allergic rhinitis separately, and how will this affect the calculation of medical complexity? Even though the J45 subsection heading includes allergic asthma, I would continue to code for allergic rhinitis as a separate code as long as you are addressing issues with the allergic rhinitis separate from the asthma. I believe it is still a separate disease and should be counted separately for medical decision making."

5 We are monitoring Xolair patients for 2 hours for their first injection. Is the 2 hour monitoring time included in the code? Yes, the monitoring will be included since most of the time it is not face to face with the provider. It is also part of the protocol. It is our understanding that J45 includes Allergic Rhinitis. How would we code a patient coming in for an Office visit, Skin testing and Spirometry with the diagnoses of (we ll specify the type) and Allergic Rhinitis (after the positive skin test)? Currently, if the patient has those diagnoses we code them: E&M +25 modifier dx: (using the proper code of course) dx: dx: Allergic Rhinitis (positive ST of course) If our providers are managing a patient with Severe Persistent asthma with daily Prednisone, and the patient presents today in clinic (for example) and their asthma is controlled and is moderate persistent today, what do they code? The patient truly has Severe Persistent that is controlled with the daily prednisone, not Moderate Persistent asthma. At first, we were under the impression that they should diagnose and code as to how the patient is on this particular day. However, the providers don't feel that is correct. They claim they should still code and diagnose the patient with Severe persistent asthma. 1. I have a few more questions regarding ICD-10 coding. The doctors in our practice have heard that every time we use a J code (asthma codes), we must also use a tobacco or smoking code. Is this so, and if the patient has never smoked, what code would we use? We can't find a code. Is this indeed a requirement? 2. If the patient has a "family history of asthma" is it a requirement to code? Do we code this on the initial visit only, or each and every visit? 3. Is there any benefit to us for using this history of asthma code? I would code the patient in the same manner as you are currently coding the patient. There is not an Excludes 1 with the allergic rhinitis codes and asthma. They are two separate disease states which affect two different parts of the respiratory system. I would code both as you are currently. According to your scenario below, you code for the patient's condition on the day of the encounter. You indicate the patient is now moderate persistent. I know the physicians believe the patient is still severe persistent and as a coder, I will code as the physician documents. At some point in time, we may have the ability to code controlled and uncontrolled which would be more appropriate for the patient. Currently we do not have that ability. Again, it is their medical opinion on which stage the patient's asthma is on the day of the encounter. 1. If you read the subsection instructions for the J chapter, it guides the coder to add the tobacco and/or exposure to tobacco code to the diagnosis code for the encounter. If the patient does not have an exposure, history of or dependence on tobacco, you would not add any additional code. 2. You should only use the "family history of asthma" code if it impacts the patient and the management of the patient's condition on each encounter. 3. The most benefit for using the family history of asthma code would be to support testing on a patient with either unusual symptoms or no symptoms to support the diagnostic testing.

6 I was referred a patient for PFT evaluation prior to starting inhaled insulin (which has a boxed warning for asthma or COPD and recommends a baseline FEV1, as well as a history and physical exam assessing for respiratory disease). I did PFTs, but also had to do a visit to establish that the patient did not have a history of asthma symptoms that might factor in to understanding if the patient has asthma (i.e. you can have a "normal" FEV1 and still have asthma). I have seen guidance as to how to code the spirometry but can I bill for the visit? If a patient comes in and a spirometry is done to rule out asthma, how is that billed? Yes, you may bill the visit. Base your visit on history exam and medical decision making and use not only your diagnosis code for your asthma or respiratory condition but also the diagnosis code for the diabetes since this diagnosis is part of your medical decision making. If you are performing a spirometry on a patient to rule out asthma, you should use the diagnosis for their signs and symptoms to support your spirometry. I have done some research to determine what the appropriate administration code would be for use with J2357 Xolair. There seems to be some controversy over this. Could you share your recommendation for using or 96372? Under current guidelines, staging can be done under initial visit, but once a patient returns its more about control. The current ICD-10 codes don t seem to reflect this. On a subsequent visit, is it true that staging is based on the stage that correlates with the stage? That would correlate with the medication used rather than the symptoms, since the meds on subsequent visit essentially can suppress symptoms and alter patient presentation. EX: You could have a severe asthmatic on highest dose asthma inhaler such as Dulera 200/5, but be controlled subsequently and have no symptoms. I assume one would code as stage 4 severe persistent asthma based on medication. My suggested Code for this patient: severe persistent, stable J45.50 is this correct? If a patient only has asthma and is allergic to pets and pollen, but does not have allergic rhinitis how would you code it? The doctor would like to know: 1. How to code for Xolair injections? 2. If the patient has asthma and is allergic but does not have allergic rhinitis how to code for that? The guidelines for the correct administration code for Xolair currently would be to follow your payer guidelines. There is more documentation required for the since it is more than a therapeutic injection. The 96401, however, is not currently recognized by some payers as the appropriate administration code. Check your payer guidelines and if there isn't a requirement, you may choose either. You are correct on your coding for the patient. You would only code the asthma based on the new guidelines for each category of code. The asthma codes are now defined by mild, moderate or severe as well as intermittent and persistent. The allergic asthma is included in these descriptors. You will choose the appropriate code based on the above criteria not on allergic asthma. Genetech may have new guidelines on their website so you may check their site.

7 Please clarify billing for a nebulizer treatment with drugs compounded: albuterol, saline, dexameth sodium phosphate. Under current guidelines, staging can be done under initial visit, but once a patient returns its more about control. The current ICD-10 codes don t seem to reflect this. On a subsequent visit, is it true that staging is based on the stage that correlates with the stage? That would correlate with the medication used rather than the symptoms, since the meds on subsequent visit essentially can suppress symptoms and alter patient presentation. EX: You could have a severe asthmatic on highest dose asthma inhaler such as Dulera 200/5, but be controlled subsequently and have no symptoms. I assume one would code as stage 4 severe persistent asthma based on medication. My suggested Code for this patient: severe persistent, stable J45.50 is this correct? A patient was seen two years ago and was diagnosed to have mild intermittent bronchial asthma. Now the patient is seen today, doing well, not taking any asthma medication. Is this patient still coded as mild intermittent asthma? A patient has mild intermittent asthma and exercise induced bronchial asthma. Are both diagnosis codes permitted at the same time Does the treatment define the severity? Ideally the severity defines the treatment. Much of the definition of severity for asthma has a time dependent aspect (episodes per unit time). Furthermore, as allergists we recognize that over time this can change. In most cases, the specialist does not see the asthmatic with the first episode and severe persistent disease is not that with the first episode. will flare and will improve based upon treatment. As we see a patient in follow-up for whatever severity of asthma may be applicable from the prior visit, we are to ascertain control and if so, the opportunity to step down and if not controlled what is needed to gain control. Does the diagnosis (severity) change over time and, assuming this is the case, do we retire the prior diagnosis and replace it with the new diagnosis? You may bill for nebulizer treatments with the CPT code If you perform a pre and post spirometry, the nebulizer will be included in the pre and post spirometry. You may also bill for the medications you purchase with HCPC J code. You are correct on your coding for the patient. According to your old guidelines, yes, the patient would be still mild intermittent bronchial asthma, but with the new guidelines for diagnosis coding, we are to code based on the patient's status when they are seen. If they still have asthma, you would still code for the patient's asthma status. If you document and address both in your note, code both. For ICD-10 coding purposes, you code for the patient per encounter. In light of that direction, I would say you would be retiring diagnoses and adding a more current diagnosis per the individual encounter.

8 Often patients are instructed to follow-up their office visits with RAST testing at their participating labs. Once the office receives the results, the doctor calls the patient to discuss. Often these phone conversations are very involved and detailed with the patient asking many questions for further clarification of their food allergies. The doctor is asking if he can submit a bill to the insurance company when he is spending 15 to 20 minutes time on the phone with these particular patients. If so, what would be the appropriate code, and would a modifier be appropriate? I submitted a bill with the following codes: 99205, 94060, 94664, modifier 25. After submitting the bill, I was told that is a component of During this encounter, I taught the patient how to use both Albuterol HFA and Flovent HFA. Given that I demonstrated technique for use of Flovent, can I still bill and with modifier 59 in this specific case? I was wondering if you can code for Xolair Injections for Buy-and-Bill? The codes for telephone calls are in the E/M section of the CPT book You must meet the requirements of the code in order to bill for the services which limits the timeframe when patients are seen back or prior to. Otherwise, when the patient is seen back the decisions made via the telephone can count toward the appropriate level of medical decision making. If your documentation is supportive of the teaching as a separate service from the Pre and Post spirometry, you would be able to support the with a 59 modifier to indicate it wasn't the MDI used to perform the pre and post spirometry (94060). The is for the administration of the Xolair. If you purchase the Xolair, you would use the J2357 code for the Xolair itself. Could you please tell me if we would be able to code for an asthma and allergy is for a preventive service, not for a patient who has allergies and asthma. You should check? We were not able to find anything on it. be using the codes. Can you kindly provide the CPT codes for Pulmonary Function Testing (PFT)? For the multiple spirometries, I would use the For open challenges the MD does a spirometry before and after the open challenge. What is the proper code to bill for the multiple spirometries? No MDI or neb treatment is being given. Also, when the physician has stated that a patient has bronco-spams at the height of their allergy symptoms, what is the best diagnosis code to use for this? I am wondering what information you may have to provide regarding nursing asthma education and using CPT Is there a check list of sorts? It was recently brought to my attention that we are able to bill using code for patients who receive the ACT test. Is this accurate? I would use the which is for multiple spirometries. The diagnosis code for bronchospasm is In order to charge for the asthma education code 98960, your nurse must be certified as an asthma educator. There is also a standardize asthma education plan which they follow. The is listed under the Other Preventive Services heading. The ACT is for a patient who has asthma. I think this will be payer specific, if the payer allows you to use the code for ACT test."

9 Can you kindly provide the CPT codes for Pulmonary Function Testing (PFT)? Can you clarify whether or not smoking status codes are required to be submitted with ALL J codes? I am specifically concerned about allergic rhinitis codes, the J30 series. I noticed in the notes preceding the respiratory chapter, the smoking status codes are suggested to add "where applicable, and then these notes are repeated in most of the J categories, but not all. Can we bill for code S8110 (Peak Flow Reading) for third party payer? When can this code be billed and would we need to use a modifier? Ex. Can we bill code with a spirometry? I am having trouble finding an appropriate code for the peak flows - I have a code of or have used the vital capacity CPT code- is this appropriate and is this reimbursable? What about the mouthpiece used with the nebulizer machine or spirometry - A Is this reimbursable, and is it encouraged to use this in addition to the neb/spirometry code? Our question has to do with CPTs (bronchodilation responsiveness, spirometry & pre/post bronchodilator administration) and (inhalation treatment). If a nebulizer treatment is performed (CPT 94640) and the bronchodilation responsiveness is performed to measure the patient s response to the treatment, is only CPT reported? I know with NCCI edits, is bundled into but a modifier is allowed. What if more than one neb treatment (94640) is administered? Would we then bill both codes with the appropriate modifier? Also, are you aware of any commercial plans that are recognizing the new modifier 59 subset modifiers (XE, XS, XP & XU)? Does the code include multiple injections or should I be billing it in units if we administer 2 injections of Xolair? Rhinolaryngoscopic Procedure with Exercise Challenge: We started doing rhino laryngoscopes with the exercise challenge to define the presence of vocal cord dysfunction, but are having very poor reimbursement, regardless of modifiers. The most common codes used by allergist for pulmonary function tests are the spirometry, or for the basic PFT. The pre and post spirometry with a bronchodilator is If you are considering providing exercise challenges or a simple pulmonary stress test, it would be coded with If you are wanting a more specific test, I would need to know what specifically you are wanting. Since the information about smoking is under the chapter heading, you should be providing it with any of the codes in the J chapter. S 8110 is for Blue Cross and other third party payers - not Medicare. You would only need to use a 25 modifier on the E/M and you should also be able to bill for a spirometry, if necessary. You would need to have a modifier on the S8110XU showing you were providing two complete separate services. There isn't a CPT code which is appropriate for a peak flow. It is included in the E/M, such as an oximetry is also included. If you have purchased the mouthpiece you may charge for it. You may find the insurance places it in durable medical goods, however. If you are performing a pre and post spirometry with a bronchodilator (94060), the bronchodilator, whether it is a MDI or a nebulizer, is included in the If you administer an additional bronchodilator, you would need to charge it as a separate service. With commercial payers, who have not indicated they will recognize the new X- modifiers, you will use the 59. For Medicare you would now use the XU modifier with appropriate documentation. You should be billing in increased units, if you provide more than one injection of Xolair (96401 x2)." You would be charging for the laryngoscopy (31575) and the exercise challenge (94620). I would need to see your EOB or your billing to give any further advice."

10 I am a practicing allergist and AAAAI fellow. The question of whether we should bill out a procedure or not was raised in our group. Specifically, quantification of FENO is used as a test of airway inflammation. Occasionally, a patient is not able to produce a valid effort. In this setting we still need to pay for the cost of the attempted measurement. Is it permissible to bill out with documentation that testing was not reproducible, or better to just eat the cost so to speak? CMS guidelines imply that there is almost no situation in which an E and M code with modifier 25 can be used when a pulmonary function test is performed. They suggest that the E and M component to the visit is inclusive in the code for the PFT. I feel very strongly that this is a very unjust situation. PFT's are a recommended tool for the management of patients with asthma. In fact the Expert Panel Report 3, 2007 Guidelines state " The following frequencies for spirometry tests are recommended: (1) at the time of initial assessment (2) after treatment is initiated and symptoms and PEF have stabilized (3) during periods of progressive or prolonged loss of asthma control, and (4) at least every 1-2 years" "I would charge for the FeNo if there has been an attempt. I would also keep any documentation of the attempt to justify your payment. Since you cannot divide the code into the professional and technical components, I would document your attempt and the inability to have a valid determination based on the patient's inability to perform the test." "The CMS guidelines you are referencing, I assume you are CCI. You may charge for an E and M encounter with a PFT, as long as you use the 25 modifier on the E/M service. The E/M needs to be necessary and not just to enable the PFT. In other words, if the patient is having an exacerbation and needs treatment, or if the patient needs to have medication checked and this is determined by the PFT, all of those scenarios would be appropriate to charge and E/M with a PFT." It does not seem right to prohibit billing for both an E and M visit and a PFT on the same day for a follow-up visit of an asthma patient. In a routine visit for an asthma patient, a careful interim history has to be obtained, as well as physical exam, and a review of medication compliance, effectiveness and side effects. It seems wrong that one cannot bill for this component as well as the PFT, which is reimbursed at a lower rate than a level 3 office visit. The CMS guidelines would also suggest that one could not bill E and M and PFT in the case of a follow-up visit for a patient having an asthma exacerbation. Please give me your thoughts and advice on when it would be appropriate to bill for an E and M and PFT in the same encounter? A patient with stable asthma is seen every 6 months or so, and has been having no problems. You are seeing them again for a routine follow-up and again everything is OK, but it has been over a year since a pft was done. Could you bill for both the office visit and the pft? What, if any, is the minimum time interval there should be between repeat PFT s, as a matter of routine? "Your time frame for your PFT's is probably patient specific and then there are guidelines under the practice parameters which you can use as well. Yes, you can bill for the PFT when the patient is presenting and having no problems. I have had many allergists share with me the patient may be having no issues but the PFT is not at an optimal level for the patient."

11 My providers have a couple questions regarding an e-news that I received from Medicare yesterday with regards to correct coding for the administration of Xolair. It says that we should not use the chemotherapy administration code that we were told to use in the beginning, but should instead bill the therapeutic prophylactic or diagnostic injection code along with the J2357 code to specify the Xolair. With this being said, we do not bill Medicare for any Xolair injections. We are currently billing all of commercial insurances with the CPT code and have been getting reimbursed. Is this correct, and the above article refers only Medicare, or should we change and bill the for all insurances? When coding for a patient with acute asthma who has mild persistent asthma, can you use the 2 codes mild persistent asthma, and acute asthma? Recently we received a rejection for Xolair from Medicare. I have written the details of this submission. A patient with Medicare as their Primary Insurance receives Xolair injections every two weeks. After an accident, the patient was under the care of a nearby inpatient rehabilitation facility. During their stay, the patient was due for their Xolair and the inpatient facility was unwilling AND unable to administer the patient s Xolair (a Medicare buy and bill medication) at their facility. The patient was granted a pass to leave the rehabilitation facility to receive their medically necessary injections at our private office. We submitted billing as follows for the administration and the drug: & J2357. It was sent with a POS of 11 and a TOS of 1 due to being performed in an office. According to Medicare, the explanation of the decision is as follows: the service rendered was reported using an office place of service. However, the Common Working File (CWF) records confirm the patient was an inpatient on this date of service. Therefore, the service is not covered because the office place of service is not consistent with the CWF record. Was this coded incorrectly? Does this fall under the Medicare claims processing Manual Transmittal Section Site of Service Payment Differential? How can we prevent this in the future? As we are not a facility, coding it with a facility code seems wrong as well. Can you let us know if the code is payable? We are starting to provide our patients with the eucapnic voluntary hyperventilation (evh) screening. Is there a CPT code established for this procedure? "Because you have payer specific guidelines, you must follow the payer for Xolair billing. Medicare carriers vary and it sounds as though your carrier has decided to recognize the for Xolair. You can continue to bill your commercial payers with the 96401, as long as you are within their guidelines." You should use only the code for mild persistent asthma, and then if the patient is having an acute exacerbation change the last digit to indicate the acute exacerbation. The diagnosis code for ICD-10CM would be J "Unfortunately, your billing for your Xolair patient needs to match where the patient is currently located. The injections are included in the rehab facility billing. You could either have the facility charge for it, and they pay you or appeal. Since you are appealing, make sure to indicate that the facility was unable and unwilling to administer the Xolair, and it was medically necessary for the patient to have the injection during their time in the facility. This is not an uncommon snag for services for patients in a facility." "94200 is not for a peak flow is for maximum breathing capacity, maximal voluntary ventilation is a payable code; but not if it is charged in addition to any other pulmonary codes." "I would recommend you consider (Bronchospasm provocation evaluation with multiple spirometric determination) for your EVH screening."

12 Our allergy practice has had a request to perform PFT s for some patients of a PCP who does not have spirometry equipment. This is related to use of a specific new inhaled insulin. The patients would not be having an office visit with us, but only a PFT test. Are there certain rules and regulations related to CPT that would prevent us from billing this code without an actual office visit by one of our providers, or can the PCP send the patient over and we bill only the either TC or global? Are there any differences you are aware of with Medicare or other carriers that would prevent this? I m wondering about Diagnostic supervision rules or incident to or anything of that nature We are having increased problem with reimbursement for multiple Xolair codes. We use cpt code with the modifier 76 and are paid by most plans, but are constantly having a problem with our Anthem Medicaid plan (Healthkeepers Plus.) They will only pay 1 injection and will not tell us which modifier they want. They just deny payment, no matter which modifier we use 76 or 59. Are we using the correct administrative code? Should we use 96401? What CPT code should I use to bill the administration of Xolair? Also, would it be appropriate to bill a along with the Xolair administration? My physicians would like to know why a code is not appropriate. Our nurses check the patient s height, weight, BMI, blood pressure and age. An asthma control questionnaire is given to the patient and a spirometry is performed. They confirm the patient has a self-injectable epinephrine on their person before giving the Xolair injection. The patient waits 30 minutes in our office before they can leave to ensure there are not reactions to the Xolair. If you could explain why this is not enough for billing a 99211, I would appreciate it. We just received a request for refund today from Blue Cross NY for a patient who receives Xolair injections in our office semi-monthly. Blue Cross is stating that their new policy, effective 10/1/2013 (over 2 1/2 years ago!), allows only 1 unit of per day, despite the number of injections received. "You are being asked to perform as an ancillary diagnostic service. You may charge the 94010TC and then have the professional component be performed by the PCP office. If the PCP's office is requesting an interpretation in addition to the performance of the spirometry, then you could bill globally (94010). The supervision guidelines are general supervision for a spirometry. When you bill out the claim the physician ordering the service will be the PCP not your physician since you do not have any relationship with the patient." "Xolair is different than most other therapeutic injections. There is more work and the does describe the use of monoclonal antibodies as the appropriate code when they are administered. If your payer requires you to use the 96372, then you must. If there isn't a requirement for the use of either code, the is appropriate. As far as multiple injections, you may try increasing the number of units and billing on one line with a unit value of 2 or 3 instead of one and see if the computer will process your claim in that manner. It appears you have used the appropriate modifiers and have not had any luck. You may also check their medical policy and see if there is a capitated amount they will cover on one day." "It is not appropriate to bill the with either of the codes for administration of the Xolair. The code choices to choose from are for a therapeutic injection OR administration of a monoclonal antibody. You may bill a physician E/M code with either of the two codes if the physician has an encounter with the patient in addition to their injection." "You may bill for the spirometry; but there is a bundling edit which indicates you cannot bill for an injection and a nurse visit at the same encounter. You may check the NCCI edits which many of the payers use and verify this information." I have heard this from a few other practices, but you need to ask which bulletin the guidelines were published. If they can provide you that information, you may need to then approach BC and see who is advising them as to their policies since Xolair is usually given in multiple doses.

13 My practitioner has a question regarding coding for Xolair injections. We were told that when a patient receives a Xolair injection and an allergy injection during the same date of service that we can code them both. So, for example, our patient, Mrs. X, sees the doctor, receives an allergy shot, a spirometry test and a Xolair injection during the same visit/date of service. We have been coding: with modifier It seems the Blues, i.e. Personal Choice, Keystone and Highmark, have been paying for both the allergy shot and the Xolair injection when we code this way. However, Medicare, United Healthcare and Cigna are bundling the allergy shot and the Xolair injection and paying the lesser amount for the allergy injection. Would you please advise us so that we will be paid for both the allergy shot and the Xolair injection? You should have a modifier on the to show it is separate from the You can use either the 59 modifier or one of the new X modifiers (XU) if it is for Medicare.