HealthCare News

Synagis

Issue: #391 NOV2016

Topic: Coding/Billing


Claims for Synagis must be submitted with CPT®code 90378 (Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg each). The administration of Synagis is billed with CPT® code 96372 (therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). The number of units (1 unit=50 mg) is recorded in field 24G of the CMS-1500 claim form. The number of milligrams administered is recorded in the description field on EMC claims or in field 19 of the CMS-1500 claim form.

See the Medical Policies section for the Synagis medical policy.

To facilitate claims processing, providers should submit ICD-10 diagnosis codes P07.20-P07.39 to identify gestational age of the infant in addition to any other appropriate diagnoses. For institutional billing on the UB-04, use revenue code 0636.

The first dose of Synagis may be given in the outpatient clinic setting on the same day as discharge from the acute hospital; however, reimbursement will be for the drug only. An office call should not be billed and will not be reimbursed, as the discharging physician will have already performed an evaluation and management service on the infant.

Drugs must be billed through physician services. The method by which the physician obtains the product is at the discretion of the physician, but only the physician (not the supplier) may bill Blue Cross Blue Shield of North Dakota (BCBSND).

Coordination of claims for families of multiple births (such as twins, triplets, etc.) will be reviewed for reimbursement of total number of vials used on the same day and the allowance will be prorated across the individual member’s claims. Claims should be submitted with the correct number of units (1 unit = 50 mg) in field 24G and milligrams administered must be submitted in the description field on EMC claims or field 19 on the CMS-1500 claim form.

The example below shows billing for Synagis administration to a set of twins. Twin A receives 67 milligrams and Twin B receives 70 milligrams. A 100 mg vial and a 50 mg vial are used.

The claim for Twin A is billed with 2 units in field 24G and 67 milligrams in field 19.

The claim for Twin B is billed with 2 units in field 24G and 70 milligrams in field 19.