Update 10/6/23: The American Medical Association has approved two new codes for nirsevimab. Please see https://publications.aap.org/aapnews/news/26439.
Monoclonal antibody products palivizumab (Synagis) and nirsevimab (Beyfortus) have been shown to protect infants and young children from severe disease caused by respiratory syncytial virus (RSV) infection. These products are not vaccines and are not for the treatment of RSV.
Following is guidance on how to code for both products.
Palivizumab (Synagis)
Dosing
Palivizumab is indicated for eligible high-risk infants and children up to 24 months of age. It is administered intramuscularly at a dosage of 15 milligrams (mg) per kilogram (kg) of body weight once prior to the commencement of the RSV season, then four doses administered monthly throughout the RSV season.
Product code
Report the following Current Procedural Terminology (CPT) product code for palivizumab based on the dose administered:
90378 Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular (IM) use, 50 mg, each
Based on payer policy, report wastage of palivizumab with either a JW modifier or divide the total milligrams injected by the total milligrams of the vial (50) to come up with the specific number of units of CPT code 90378. See vignette 3 below.
Nirsevimab (Beyfortus)
CPT codes 90380 and 90381 were approved by the American Medical Association’s CPT Editorial Panel in May and released on June 30.
Dosing
Nirsevimab is recommended for:
- all infants younger than 8 months born during or entering their first RSV season, including those recommended by the AAP to receive palivizumab, and
- infants and children ages 8 through 19 months who are at increased risk of severe RSV disease and entering their second RSV season, including those recommended by the AAP to receive palivizumab and American Indian and Alaska Native children.
Dosing is based on weight and age. One 0.5 mL dose should be administered to infants younger than 8 months weighing less than 5 kg (CPT code 90380). One 1 mL dose should be administered to infants younger than 8 months weighing 5 kg or more (CPT code 90381).
Children receiving nirsevimab in their second RSV season should receive a 2 mL dose (CPT code 90381), administered through two separate 1 mL IM injections.
Product codes
Report the following product codes for nirsevimab based on the dose administered:
90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use
90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use
When the immunoglobulin product is provided through the Vaccines for Children program, follow state and managed care organization guidelines for reporting the immunization. Some states require the SL modifier on the product code to indicate it is a state-supplied product; other states require the SL modifier on the administration code.
Administration codes
Report the administration of palivizumab and nirsevimab with code 96372 (injection of a drug or substance, subcutaneous or intramuscular). Do not report immunization administration codes 90460-90461 or 90471-90472, as these codes are limited to the administration of vaccine and toxoid products.
Diagnosis codes
Administration of nirsevimab is not reported with Z23 Encounter for immunization. Z23 is specific to immunization related to vaccines. While nirsevimab is categorized as a monoclonal antibody by CPT, International Classification of Diseases, Tenth Revision, Clinical Modification’s (ICD-10-CM) index guides us to code Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV). Using the appropriate diagnosis code is important not only for billing and claims payment, but it also is necessary for data collection and quality metrics.
The AAP is advocating for a new code to support nirsevimab administration, including the associated counseling.
Below are examples of how to report the administration of nirsevimab and palivizumab, along with other services.
Vignette 1
An 18-month-old established patient weighing 10 kg with a history of severe immune compromise presents for a well-child visit. A preventive service is provided, including age-appropriate developmental screening. The physician also counsels on RSV prevention and discusses the risks and benefits of receiving nirsevimab. All of the family’s questions are answered and documented. The patient receives 2 mL of nirsevimab (two separate intramuscular injections of 1 mL each).
CPT codes
99392 Periodic comprehensive preventive medicine reevaluation and management of an established patient; early childhood (age 1 through 4 years)
96110 Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument
90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for IM use = 2 units
96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular = 2 units
Coding tip
Nirsevimab is not a vaccine and cannot be reported with ICD-10-CM code Z23 Encounter for immunization. The correct ICD-10-CM code is Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV).
Vignette 2
A 2-month-old established patient weighing 4.8 kg presents for a scheduled nirsevimab 0.5 mL injection. Counseling was provided by the physician at the well-child visit two weeks ago; mother had additional questions that were answered by the registered nurse (RN). The mother agrees to proceed with administration of nirsevimab.
CPT codes
90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for IM use
96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
Coding tips
Additional counseling provided by the RN and subsequent administration of nirsevimab do not support reporting an additional evaluation and management code such as 99211. To report any E/M code, a condition must be evaluated and managed; for coding purposes, counseling does not equate to the management of a condition.
Nirsevimab is not a vaccine and cannot be reported with ICD-10-CM code Z23 Encounter for immunization. The correct ICD-10-CM code is Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV).
Vignette 3
A 4-month-old established patient weighing 6 kg with a history of severe immune compromise presents for a well-child visit. The physician also counsels mom on the upcoming RSV season and discusses the risks and benefits of monoclonal antibodies for prevention. All of her questions are answered, and she agrees to move forward with monoclonal antibodies for RSV, as well as the infant’s routine vaccines.
Since the practice has not received its stock of nirsevimab, the physician recommends using palivizumab instead, and the mother agrees. The patient receives the first of five monthly intramuscular injections of palivizumab 90 mg (monthly injection will vary based on weight at the time of injection).
CPT codes
99392 Periodic comprehensive preventive medicine reevaluation and management of an established patient; early childhood (age 1 through 4 years)
90378 Respiratory syncytial virus, monoclonal antibody, recombinant, for IM use, 50 mg, each
96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or IM
Coding tips
Palivizumab is not a vaccine and cannot be reported with ICD-10-CM code Z23 Encounter for immunization. The correct ICD-10-CM code is Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV).
Based on payer policy, report 2 units of 90378 with a JW modifier or report 1.8 units of 90378 to indicate wastage of product (90mg/50mg = 1.8 units).
Look to AAP News for updates to guidance and coding related to monoclonal antibodies for the prevention of RSV.
