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Our Services Reimbursement

Coding for XOLAIR® (omalizumab)

 

 

This table is provided for informational purposes only. Correct coding is the responsibility of the provider submitting the claim for the item or service. Please check with the payer to verify codes and special billing requirements. Genentech and Novartis Pharmaceuticals Corporation do not make any representation or guarantees concerning reimbursement or coverage for any service or item.

 

 

Please visit CMS.gov or other payers’ websites to obtain additional guidance on their processes related to billing and coding for single-use vials and wastage.

 

  •   Moderate to Severe Persistent Allergic Asthma
     Chronic Idiopathic Urticaria
    Type  CodeDescription
    Select Diagnosis:
    ICD-9-CM1*

    Moderate to Severe Persistent
    Allergic Asthma
    493.00 Extrinsic asthma, unspecified
    493.20 Chronic obstructive asthma, unspecified
    493.90 Asthma, unspecified
    Select Diagnosis:
    ICD-9-CM1*

    Chronic Idiopathic Urticaria
    708.1 Idiopathic urticaria
    708.8 Other specified urticaria
    708.9 Urticaria, unspecified
    NDC 10-digit 11-digit  
    50242-040-62 50242-0040-62 150-mg single-use vial
    Drug: HCPCS J2357 Injection, omalizumab, 5 mg
    Select Procedures, Services and Supplies: CPT|| 96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
    96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic#

     

    * International Classification of Diseases—9th revision—Clinical Modification.
    This description corresponds to the ICD-9 codes as determined by the Centers for Medicare & Medicaid Services. Please refer to the XOLAIR indications below.
    National Drug Code.
    § Healthcare Common Procedure Coding System.
    || Current Procedural Terminology (CPT®).
    XOLAIR is for subcutaneous use. Please refer to the XOLAIR indications below.
    # XOLAIR is not an anti-neoplastic agent. Please refer to the XOLAIR indications below.

     

     

    REFERENCES

    1.

     National Center for Health Statistics and the Centers for Medicare & Medicaid Services. The International Classification of Diseases, 9th Revision. Clinical Modification (ICD-9-CM), 6th edition. Hyattsville, MD: US Dept of Health and Human Services; 2011.

    2.

     Centers for Medicare & Medicaid Services. 2013 table of drugs. http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Downloads/DRUG2013.pdf. Accessed December 4, 2013.

NEXT TOPICAppeals 

Appeals

If your office has prescribed XOLAIR® (omalizumab), but your patient’s insurer has denied coverage, you can appeal that decision. XOLAIR Access Solutions and the XOLAIR Specialty Pharmacy Network might be able to help you as you resolve the situation. Here is what you can do*:

 

  1. Understand why the request or claim has been denied. This should be in the insurer’s letter of denial or the patient’s Explanation of Benefits letter.
  2. Contact a specialty pharmacy or XOLAIR Access Solutions for guidance as you put together an appeal. Use these resources to help you gather the documents and information you need for a appeal.
    • If the patient is already working with a specialty pharmacy, it will provide support throughout the appeals process
    • If your patient is not working with a specialty pharmacy, refer the case to XOLAIR Access Solutions for appeal support. We provide support for appropriate patients who aren’t being helped through a specialty pharmacy
  3. Complete and submit the required forms and documents to the insurer before the appeal deadline. XOLAIR Access Solutions or the specialty pharmacy can provide information about this process.
Below are some helpful files for handling common issues in denials. Download will occur automatically on selection.

  

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View/Print a form or document as a PDF.