New Current Procedural Terminology (CPT) codes have been approved for the administration of nirsevimab (Beyfortus), a monoclonal antibody designed to protect infants and toddlers from severe disease caused by respiratory syncytial virus (RSV) infection.
Following is guidance on how to code for nirsevimab and palivizumab (Synagis), another monoclonal antibody indicated for eligible high-risk infants and children up to 24 months. These products are not vaccines and are not for the treatment of RSV.
CPT codes 90380 and 90381 were approved by the American Medical Association’s (AMA’s) CPT Editorial Panel in May and released on June 30.
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.
Dosing is based on weight and age. One 0.5 milliliter (mL) dose should be administered to infants younger than 8 months weighing less than 5 kilograms (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 one 200 milligram (mg) dose (CPT code 90381), administered through two separate 1 mL intramuscular (IM) injections.
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 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 to indicate it is a state-supplied product.
On Oct. 6, the AMA released released two new CPT codes specific to the administration of nirsevimab. Code 96380 is used to report the counseling and administration of nirsevimab, and 96381 is used to report the administration of nirsevimab on a different date than the counseling by a physician or qualified health care professional (QHP).
For claim dates of Oct. 6 or later, do not report code 96372 (injection of a drug or substance, subcutaneous or intramuscular) for administering nirsevimab. Report the administration of palivizumab with code 96372.
Do not report the administration of nirsevimab or palivizumab with immunization administration codes 90460 or 90471, as these codes are limited to administering vaccine and toxoid products.
Administration of nirsevimab is not reported with International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code Z23 Encounter for immunization. Z23 is specific to immunization related to vaccines.
While CPT categorizes nirsevimab as a monoclonal antibody, ICD-10-CM’s 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 also for data collection and quality metrics.
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 mg per kg of body weight once prior to the commencement of the RSV season, then four doses administered monthly throughout the RSV season.
Report the following CPT product code for palivizumab based on the dose administered:
90378 Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular 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.
Below are examples of how to report the administration of nirsevimab and palivizumab, along with other services.
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.
90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for IM use
96381 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by IM injection
Additional counseling provided by RN and subsequent administration of nirsevimab do not support reporting an additional evaluation and management (E/M) 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.
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).
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
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).