A Comprehensive Guide on How to Bill for RhoGAM Injection

Approximately 15% of the Caucasian population and 7-8% of the Black population are Rh-negative. For these individuals, a correct understanding of how to bill for rhogam injection is crucial for preventing Rhesus disease and ensuring proper reimbursement for healthcare providers.

Quick Summary

Billing for RhoGAM injections involves using the appropriate CPT or HCPCS drug and administration codes, paired with the correct ICD-10 diagnosis code, based on specific payer requirements and documented medical necessity.

Key Points

• Choose Correct Drug Code: Use either the CPT codes (e.g., 90384) or HCPCS J-codes (e.g., J2790) for the Rho(D) immune globulin, depending on the patient's payer.

• Bill Administration Separately: Report CPT code 96372 for the administration of the intramuscular injection, in addition to the drug code.

• Select Appropriate ICD-10 Code: Use a specific ICD-10 diagnosis code that provides medical necessity, such as Z29.13 for prophylactic injections.

• Check Payer Preferences: Many payers, including Medicare, have specific requirements for CPT vs. HCPCS codes; always confirm with the insurer beforehand.

• Ensure Thorough Documentation: Patient records must support the Rh-negative status, medical necessity, drug name, and dosage for accurate billing.

• Include NDC Information: For expensive drugs like RhoGAM, submitting the National Drug Code (NDC) can help ensure proper reimbursement.

• Monitor for Common Errors: Avoid denials by steering clear of issues like code unbundling, using outdated codes, or failing to include a supporting diagnosis.

What is RhoGAM?

RhoGAM, a brand name for Rho(D) immune globulin, is a medication given to Rh-negative mothers during pregnancy and after delivery to prevent the development of antibodies that could harm a future Rh-positive baby. Accurate medical coding is essential for receiving appropriate reimbursement and minimizing claim denials. A complete and clean claim for a RhoGAM injection consists of multiple components: the drug code, the administration code, and the diagnosis code(s) that justify the service.

Understanding the Components of a RhoGAM Claim

Submitting a successful claim for a RhoGAM injection requires a detailed understanding of the codes involved. This includes selecting the correct code for the drug itself, the service of administering the injection, and the diagnosis that supports the medical necessity. Common pitfalls include using outdated codes, failing to specify the correct drug dosage, or using an incorrect diagnosis code for the patient's specific condition.

Choosing the Correct Drug Code: CPT vs. HCPCS

One of the most important steps is determining which code your payer accepts for the Rho(D) immune globulin product. Payers often have specific preferences regarding Current Procedural Terminology (CPT) codes versus Healthcare Common Procedure Coding System (HCPCS) codes for the drug supply.

Code Type	Code	Description	Typical Use
CPT	90384	Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use	Commonly used by commercial or private payers for the full 300 mcg dose.
CPT	90385	Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use	Used for mini-doses, typically after a first-trimester miscarriage or abortion.
CPT	90386	Rho(D) immune globulin (RhIg), human, for intravenous (IV) use	For IV administration of the immune globulin.
HCPCS	J2790	Injection, rho d immune globulin, human, full dose, 300 micrograms (1500 i.u.)	Often required by Medicare and some Medicaid plans for the full dose.
HCPCS	J2788	Injection, rho d immune globulin, human, minidose, 50 micrograms (250 i.u.)	Used by payers requiring HCPCS codes for the mini-dose.
HCPCS	J2791	Injection, rho(d) immune globulin (human), (rhophylac), intramuscular or intravenous, 100 iu	Specifically for the product Rhophylac, depending on the payer.
HCPCS	J2792	Injection, rho d immune globulin, intravenous, human, solvent detergent, 100 iu	For IV administration of specific products.

It is imperative to verify payer-specific guidelines to know whether they prefer a CPT code or a HCPCS J-code. For example, some Medicaid plans might accept J2790, while many commercial insurances prefer 90384.

Administration Code for the Injection

In addition to billing for the drug product itself, you must also bill for the service of administering the injection. This is typically done with a separate CPT code.

• CPT Code 96372: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. This code is used to report the provider's service of injecting the RhoGAM. Do not use code 90772, which was previously used, as 96372 is the current correct code for an intramuscular injection.

Selecting the Appropriate ICD-10 Diagnosis Code

The diagnosis code provides the medical necessity for the RhoGAM injection and is crucial for a successful claim. The choice of code depends on the patient's Rh status and the reason for the injection.

• Prophylactic Administration: For routine prophylactic administration (e.g., around 28 weeks gestation), use Z29.13 (Encounter for prophylactic Rho(D) immune globulin).
• Rh Incompatibility Status: If the patient is Rh-negative but has not yet developed antibodies (no isoimmunization), use Z31.82 (Encounter for Rh incompatibility status).
• Confirmed Isoimmunization: If the patient has confirmed Rh isoimmunization (developed antibodies), use the relevant code from the O36.0 series, such as O36.019- (Maternal care for anti-D Rh antibodies, unspecified trimester). For these codes, you must add a fifth and sixth digit to specify the trimester and fetus number.

Step-by-Step Billing Process for a RhoGAM Injection

1. Verify Patient Eligibility: Check the patient's insurance for coverage and requirements. Some plans may require prior authorization for certain products.
2. Determine Payer Preference: Contact the payer or consult their coding guidelines to confirm if they accept the CPT drug code (90384/90385) or the HCPCS J-code (J2790/J2788).
3. Use the Correct Codes: Select the appropriate drug code (CPT or HCPCS), administration code (96372), and ICD-10 diagnosis code(s) that align with the reason for the injection.
4. Gather Necessary Documentation: Ensure the patient's medical record clearly documents the Rh-negative status, the reason for the injection (e.g., prophylactic, postpartum), the product's NDC number, and the lot number.
5. Submit the Claim: Submit the claim electronically using the correct claim form (e.g., CMS-1500) and populated with all the necessary codes. Ensure the date of service matches the date the injection was administered.
6. Follow Up on Denials: If the claim is denied, review the denial reason and re-file with any necessary corrections. Common issues include using the wrong code for the payer or lacking proper documentation.

Common Billing Errors and How to Avoid Them

• Using a CPT code for a Medicare patient: Many Medicare plans require the HCPCS J-code (J2790) for the drug product. Always confirm with the payer.
• Unbundling services: Do not try to bill for injection supplies separately. The administration code covers the provider's service.
• Using an outdated administration code: The appropriate code for an intramuscular injection is 96372, not 90782 or 90772, which were used previously.
• Failing to document medical necessity: An injection without a supporting diagnosis code is likely to be denied. Proper ICD-10 codes are essential. For prophylactic injections, Z29.13 is required.
• Incorrect NDC reporting: While not always required by all payers, including the National Drug Code (NDC) can facilitate proper reimbursement, especially for expensive medications.

Conclusion

Mastering how to bill for rhogam injection is a critical skill for any practice involved in obstetrics and women's health. By carefully selecting the correct CPT or HCPCS drug code, the appropriate administration code, and the most specific ICD-10 diagnosis code based on payer requirements and comprehensive documentation, medical coders can ensure clean claim submissions. Staying updated with payer-specific rules is the best way to prevent denials and secure timely and accurate reimbursement for this vital medication.

For more detailed coding information and updates, refer to the American Academy of Professional Coders (AAPC).

Frequently Asked Questions

What is the difference between CPT and HCPCS codes for RhoGAM?

CPT codes (e.g., 90384) are generally preferred by commercial payers, while HCPCS J-codes (e.g., J2790) are often required by government payers like Medicare for billing the drug supply. Always check the specific payer's guidelines.

Which code should be used for the administration of a RhoGAM injection?

The correct CPT code for the administration of an intramuscular RhoGAM injection is 96372, which covers the professional service of giving the injection.

What diagnosis code is used for routine prophylactic RhoGAM injections?

For routine prophylactic RhoGAM injections, such as those given around 28 weeks of gestation, the appropriate ICD-10 diagnosis code is Z29.13 (Encounter for prophylactic Rho(D) immune globulin).

What should I do if a RhoGAM claim is denied?

Review the denial reason to identify the error. Common reasons include using the wrong drug code (CPT vs. HCPCS), incorrect dosage units, or a missing/inappropriate diagnosis code. Resubmit the claim with the correct information.

Is documentation required for a RhoGAM injection claim?

Yes, thorough documentation is required. The patient's medical record should clearly state the Rh-negative status, the reason for the injection, and the drug details to support the medical necessity for the claim.

When should an ICD-10 code from the O36 series be used for Rh issues?

Codes from the O36 series, such as O36.019-, are used for patients who have already developed Rh isoimmunization (antibodies) during pregnancy, not for routine prophylactic injections.

Should I include the NDC number on the claim?

Including the NDC number can be beneficial, especially for expensive drugs like RhoGAM. While not always mandatory, it provides additional information for some payers and can help ensure correct reimbursement.