Reimbursement

This coding information may assist you as you complete payer forms. 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 does not make any representation or guarantee concerning reimbursement or coverage for any service or item.

ICD-10-CM Tool

ICD-10-CM:


L50.1 Idiopathic urticaria
J45.40 Moderate persistent asthma, uncomplicated
J45.50 Severe persistent asthma, uncomplicated

XOLAIR ICD-10-CM Coding

These tables are provided for informational purposes only. Many payers will not accept unspecified codes. If you use an unspecified code, please check your payer. Correct coding is the responsibility of the provider.

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.

TYPE CODE DESCRIPTION
Diagnosis: ICD-10-CM J45.40 Moderate persistent asthma, uncomplicated
J45.50 Severe persistent asthma, uncomplicated
Drug: NDC
Note: Payer requirements regarding use of a 10-digit or 11-digit NDC may vary. Both formats are listed here for your reference.
10-digit 11-digit  
50242-040-62 50242-0040-62 150-mg single-use vial
Drug: HCPCS J2357 Injection, omalizumab, 5 mg
Administration procedures: CPT 96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic

CPT=Current Procedural Terminology.
HCPCS=Healthcare Common Procedure Coding System.
ICD-10-CM=International Classification of Diseases, 10th Revision, Clinical Modification.
NDC=National Drug Code.

TYPE CODE DESCRIPTION
Diagnosis: ICD-10-CM L50.1 Idiopathic urticaria
Drug: NDC
Note: Payer requirements regarding use of a 10-digit or 11-digit NDC may vary. Both formats are listed here for your reference.
10-digit 11-digit  
50242-040-62 50242-0040-62 150-mg single-use vial
Drug: HCPCS J2357 Injection, omalizumab, 5 mg
Administration procedures: CPT 96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic

CPT=Current Procedural Terminology.
HCPCS=Healthcare Common Procedure Coding System.
ICD-10-CM=International Classification of Diseases, 10th Revision, Clinical Modification.
NDC=National Drug Code.

Appeals

If your office has prescribed XOLAIR 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 (EOB) 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 successful 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.