Take a deep breath when reviewing asthma treatments
When reviewing asthma treatments, Codoxo noted high utilization of chemotherapy injections by Allergy & Immunology specialists in association with medications to treat eosinophilic asthma and severe asthma. The injections were given in the physician’s office multiple times per patient and the claim details for the ‘J’ code indicated the drugs were billed from their office stock. Of interest, the drug administered is solely available as either a pre-filled syringe or an autoinjector device [AID]. Informatively, the autoinjector option allows the patient to self-administer the pre-measured dosage in their own home after a healthcare professional demonstrates the proper technique.
The AMA (American Medical Association) version of the CPT (Current Procedural Manual) has two distinct types of injection codes, CPT 96372 [Therapeutic] or CPT 96401 [Chemotherapy], both of which are administered subcutaneously or intramuscularly. While chemotherapy administration is typically reimbursed at a higher rate than a therapeutic injection, the payment amount would vary based on your contract with the providers and your payment policies.
Healthcare codes associated with Benralizumab
The following table outlines the HCPCS and NDC medication codes as well as CPT codes for administration of the drug by a qualified healthcare professional in an office setting.
| HCPCS / NDC | Short description | Injection Service CPT Codes | Administration |
|---|---|---|---|
| J0517 | Benralizumab 1mg | 99211 and [96372 or 96401] | Physician |
| 0310-1730-30 | Fasenra/Benralizumab | 99211 and [96372 or 96401] | Physician |
| 0310-1830-30 | Fasenra/Benralizumab | Not applicable | Patient/Caregiver |
| 00310-1730-30 | Fasenra/Benralizumab | 99211 and [96372 or 96401] | Physician |
| 00310-1830-30 | Fasenra/Benralizumab | Not applicable | Patient/Caregiver |
We reviewed the prescribing information from each manufacturer and various other sources. The literature reviewed indicated these medications are safe and easily self-administered at home or by a caregiver, or parent if the patient is under the age of 12. They also included verbiage that indicates the initial dosage should be administered in the presence of the physician to observe for side effects. After the initial dosage, the patient/parent/caregiver must be given instructions on administering the injections at home and what side effects to watch for after the injection.
What to consider when reviewing autoinjector drug claims
First, check your plan’s policy regarding Benralizumab and the approved injection CPT codes as either therapeutic and/or chemotherapy. While you should expect to at least the initial office injection claim off Benralizumab for a patient, the availability of the autoinjector device for self-administration should reduce the necessity for additional office visits and injection services when the patient or caregiver/parent is trained to use the autoinjector device. While CPT 99211 is allowed as a nursing code for any injection, another area of concern may include higher-level E&M services during scheduled or routine injection appointments.
Review your pharmacy claims for any corresponding medical claims for Benralizumab for potential duplicative or overlapping drugs claims to ensure your plan did not pay the medical provider for a drug they did not stock.
How to find Frequent Combinations of claims for injection services and Benralizumab Schemes:
- Navigate to Schemes and scroll down to the Top Codes widget
- Choose Procedure from drop-down menu and enter J0517
- When the summary appears, highlight the row, and click the Reasons view
- Click the View Providers icon for any detector reason of Frequent Combination that may include chemotherapy injection codes
- As you review the individual claim details, look for higher-level E&M services added to the injection services
If you are interested in learning more about Codoxo’s forensic AI platform or would like to speak to Codoxo team member, contact us via info@codoxo.com.
References
- Fasenra (J0517) Dosing and Coding Resources