Rho(D) aka (Rhogam) coding quandry: Two ways to code, both are correct!

It's hard to believe, but in pregnancy Rhogam administration, there are actually two correct methods to code the administration of the Rho(D) globulin serum.  As a coder, it is up to you to determine how best to accomplish this for your OB/GYN practice.  I've outlined below what you need to know to correctly code, bill and get reimbursement for this service. 

History of Rho(D)

RHo(D) Immune globulin is the serum globulin extracted from human blood, or can also be a recombinant immune globulin product that has been created through genetic manipulation of human and/or animal protein.  RH plays an important role in the pregnant patient and the developing fetus. 

Rh blood types were discovered back in 1940, and over the last 70 years researchers have learned a lot about the genetic complexities of Rh and blood typing in relationship to fetal and maternal well being.  The Rh system was initially named after rhesus monkey, since they were the initial research subjects. (and also since the rhesus monkey blood bears similar human qualities).  What was determined in these studies is that when creating the antiserum – if the antiserum agglutinates the red cells you are considered and Rh+(positive) and if it does not you are considered an Rh-(negative). 

From a clinical standpoint, the Rh factor of positive and negative can lead to problems between a mother and the developing fetus.  It is referred to as mother-fetus incompatibility, and occurs when the mother is Rh-(negative) and the fetus is Rh+(positive).  Amazingly enough, these antibodies can cross the placenta and destroy fetal red blood cells.  The risk for this happening increases with each pregnancy.

To help prevent these complications during pregnancy,  physicians routinely order the pregnant patient to undergo testing to determine the Rh and ABO blood typing.  Once this has been completed, the physician will then determine if having the patient receive the Rho(D) immune globulin. 

According to the American College of Obstetricians and Gynecologists (ACOG) they have developed a standard guideline of re administration of the Rho(D) immune globulin product

These standards are:

• The first dose of Rho(D) immune globulin is to be given at 28 weeks’ gestation (earlier if there’s been an invasive event),
• Followed by a postpartum dose given within 72 hours of delivery.

The Two Coding Scenario's 

As a coder, you need to understand the documentation requirements for the administration of a Rho(D) immune globulin, and then how to bill and code for it appropriately.  This is where the coding of the product becomes somewhat complex. 

CPT identifies the Rho(D) immune globulin serum with these three codes

• 90384 Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use
• 90385 Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use
• 90386 Rho(D) immune globulin (RhIgIV), human, for intravenous use

To code and bill the serum itself, CPT also directs us to report the administration of the serum with codes 96365-96368, 96372, 96374 or 96375 as appropriate.  CPT also instructs us that modifier 51 should not be appended when performed with another procedure.

However, CMS (Center for Medicare & Medicaid Services) the part B physician fee schedule does not recognize the coding or payment for the codes 90384, 90385 and 90386.  CMS does however recognize the HCPCS codes for Rho(D) as shown below.

• J2788 Injection, Rho D immune globulin, human, minidose, 50 mcg (250 i.u.)
• J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg (1500 i.u.)
•  J2791 Injection, Rho D immune globulin (human), (Rhophylac), intramuscular or intravenous,100 IU
• J2792 Injection, Rho D immune globulin, intravenous, human, solvent detergent, 100 IU

If you choose to bill the HCPCS codes J2788—J2792, again you will need to code and bill for the injection of the serum with either the CPT code(s) 96365-96368, 96372, 96374 or 96375 as appropriate, or with the ICD-9 Volume 3 procedure code of 99.11

This creates the issue where both methods of coding are correct.  The issue then falls upon the coder to determine how to code the service based upon how the 3^rd party payer will reimburse for the service. 

The next issue with the coding of Rho(D) in pregnancy is determining the correct diagnosis to be appended with the service rendered.  The most common diagnoses for a pregnant patient with the need for a Rho(D) are:  

V07.2          Need for prophylactic immunotherapy

V22.1          Supervision of other normal pregnancy

656.10                  Rhesus isoimmunization unspecified as to episode of care in pregnancy

656.11                   Rhesus isoimmunization affecting management of mother, delivered

656.13         Rhesus isoimmunization affecting management of mother, antepartum condition

However, there are many other pregnancy diagnoses that would denote the need for a Rho(D) injection.  The diagnosis needs to be clearly documented by the provider for the coder to accurately code and bill for the procedure.

As with any and all services, it is recommended that you pre-authorize the Rho(D) injection first with the insurance carrier/3^rd party payer.  When pre-authorizing, inquire with the carrier how they would like to see the service coded.  This will help you code and bill for this correctly up-front, and avoid payment and coding denials on the backside. 

Office/outpatient Practice

CPT Code	Description	Diagnosis
90384	Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use. (e.g. serum itself)	V07.2   Need for prophylactic immunotherapy V22.1   Supervision of other normal pregnancy 656.13 Rh Iso afft mgmt of mother antepartum
96372	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (e.g. injection of the serum)	V07.2   Need for prophylactic immunotherapy V22.1   Supervision of other normal pregnancy 656.13 Rh Iso afft mgmt of mother antepartum

Office/outpatient Practice

HCPCS/CPT Code	Description	Diagnosis
J2790	Rho D immune globulin, human, full dose, 300 mcg (1500 i.u (e.g. serum itself)	V07.2   Need for prophylactic immunotherapy V22.1   Supervision of other normal pregnancy 656.13 Rh Iso afft mgmt of mother antepartum
96372	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (e.g. injection of the serum)	V07.2   Need for prophylactic immunotherapy V22.1   Supervision of other normal pregnancy 656.13 Rh Iso afft mgmt of mother antepartum

 

Inpatient/Outpatient Facility

HCPCS/ICD-9 vol 3 procedure code	Description	Diagnosis
J2790	Rho D immune globulin, human, full dose, 300 mcg (1500 i.u (eg. serum itself)	V07.2   Need for prophylactic immunotherapy V22.1   Supervision of other normal pregnancy 656.13 Rh Iso afft mgmt of mother antepartum
99.11	Therapeutic, prophylactic, or diagnostic injection of Rh Immune Globulin	V07.2   Need for prophylactic immunotherapy 656.13 Rh Iso afft mgmt of mother antepartum This creates the issue where both methods of coding are correct.  The issue then falls upon the coder to determine how to code the service based upon how the 3rd party payer will reimburse for the service.