Mastering Medical Coding for Monoclonal Antibody Immunization: Insights into 2024

Infusion services remain a vital component of medical treatment for patients across the nation, each area containing its own complexities that create challenges for coders and compliance professionals alike. In July 2023, the FDA gave the green light to Beyfortus™ (nirsevimab-alip) for infants under eight months old encountering their first respiratory syncytial virus (RSV) season and certain high-risk children aged 8–19 months entering their second RSV season. While nirsevimab acts as a preventative measure against illness, it is crucial to understand that the FDA categorizes it as a drug rather than a conventional vaccine. This classification has triggered uncertainty among medical coders regarding the appropriate CPT^® code for reporting administration and how to account for counseling efforts, particularly in pediatric settings. Let’s analyze more of the specific details for accurate understanding and successful outcomes throughout 2024 and beyond.

Deciphering CPT Codes

Initially, providers were guided to use CPT code 96372 for administering nirsevimab. However, in September 2023, the CPT Editorial Panel authorized immunization administration codes 96380 and 96381, effective from October 6, 2023. Understand that these codes are not yet included in the 2024 CPT Manual but are slated for inclusion in the 2025 edition, positioned after code 96377. This update streamlines the coding process, ensuring accurate reporting of nirsevimab administrations.

ICD-10-CM Coding Clarifications

Unlike traditional vaccines, the administration of nirsevimab is not reported with the ICD-10-CM code Z23 (Encounter for immunization). Coders should understand that this diagnosis code is specific to immunization related to vaccines.

 Instead, coders should refer to Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV). Utilizing the correct diagnosis code is pivotal for billing accuracy, claims processing, and data integrity. Moreover, when administering nirsevimab to patients with high-risk conditions, it’s essential to append code Z29.11 alongside the relevant ICD-10-CM code corresponding to each patient’s specific high-risk condition.

The below product codes for nirsevimab became effective July 17, 2023:

www.ama-assn.org/system/files/vaccine-long-descriptors.pdf

When should the above codes be reported? Assign either CPT code 90380 or 90381 on all claims for Beyfortus (nirsevimab-alip). Understand that these codes are specific to passive immunization for pediatric seasonal dose for RSVb and are differentiated by dose description of 0.5-mL dose and 1-mL. For clarity, report as one unit of 90380 when a 0.5-mL dose is administered. Report as one unit of 90381 when a 1-mL dose is administered and submit two units of 90381 when a 2-mL dose is administered.

It’s worth noting that the monoclonal antibody palivizumab carries the product code 90378 and is not to be reported with administration codes 96380 or 96381. The guidance provided by the AMA instructs healthcare providers to utilize the new CPT codes specifically designated for the administration of respiratory syncytial virus monoclonal antibody seasonal doses, outlined as 90380 and 90381. For a more comprehensive discussion on coding pertaining to the administration of vaccines or toxoids, refer to Chapter 19.

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Additional references and guidance may be found at the website of American Academy of Pediatrics:

https://www.aap.org/en/patient-care/respiratory-syncytial-virus-rsv-prevention/nirsevimab-frequently-asked-questions/

https://www.aap.org/en/patient-care/respiratory-syncytial-virus-rsv-prevention/nirsevimab-coding–payment/