Visante 
Seems like a slam dunk, doesn’t it? A patient comes to the Emergency Department with an animal bite. A standard CDC protocol for rabies post-exposure prophylaxis (PEP) outlines initial therapy with both rabies immune globulin and rabies vaccine, with additional vaccine on Days 3, 7, and 14. An 5th dose of vaccine may be needed on Day 28 if the patient is immunocompromised.
What can possibly go wrong with the reimbursement? Well apparently a lot, since we see many write-offs, mostly for visits when the patient returns to the Emergency Department for their subsequent vaccine doses.
The CDC tell us that 55,000 Americans receive post-exposure prophylaxis for rabies each year, so that’s approximately 220,000 ED visits per year, and it is predominantly in areas where there are wildlife such as bats, raccoons, skunks, and foxes. Just for the immune globulin alone, the estimate is over $165 million in reimbursement. Almost all State Health Departments have stopped providing rabies immune globulin and rabies vaccine at no charge, so these patients all end up in hospital emergency departments.
What do I need to do to prepare claims for rabies treatment?
1. There are two CPT codes for rabies immune globulin, 90375, and 90376 if the product is heat-treated. Typically, the heat-treated product is reimbursed at a higher rate (about $58 more per 150 I.U. from Medicare effective October 1, 2020) so it’s important to get the code right based upon the product used. There are two different codes for rabies vaccine, 90675 for intramuscular and 90676 for intradermal. These also have a payment differential.
2. Rabies immune globulin is available in two strengths depending upon the product: 150 international units (I.U.)/ml and 300 I.U/ml. CMS indicates on the ASP NDC-HCPCS crosswalk that CPT codes 90375 and 90376 should be billed per 150 I.U. so the billing set-up is important. It’s also important that you don’t inadvertently bill “per vial” since the products come in multiple product sizes and per vial charges always result in lost revenue.
3. If a portion of the immune globulin product is used for infiltration, the amount should be clearly documented in the medical record in addition to the amount administered intramuscularly so the total amount can be billed.
4. If any amount is discarded, it should be documented in the medical record and billed as drug waste (with a JW modifier if required by the payer).
5. Emergency department caregivers should be reminded to clearly document return visits as post-exposure prophylaxis as well as the suspected animal.
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The coders can then be specific in coding as payers may distinguish coverage based upon whether the vaccine is administered:
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for prophylaxis (Z23 (encounter for immunization)) or,
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post-exposure prophylaxis (Z20.3 (contact with and (suspected) exposure to rabies)).
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Payers often do not pay for routine immunizations, but do pay for post-exposure prophylaxis.
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The specific “Z” code on the claim distinguishes the two. Documenting “contact with suspected exposure to rabies” should be done for EACH ED visit.
6. ICD-10-CM codes are unique and distinguish between bites by mice, rats, squirrels, other rodents, dog, cat, horse, cow, other hoof stock, pig, raccoon, and other mammals.
During times of drug shortage, the WHO recommends intradermal administration as a means to preserve vaccine supplies which uses fewer vials. Since this is an off-label dose and route, we recommend documenting in the patient’s medical record that rabies vaccine was in short supply which necessitated the intradermal administration protocol.
SHOUT-OUTS!
1. The Pharmacy Department should ensure that the correct HCPCS codes are billing for the administered product and that heat-treated rabies immune globulin is distinguished from non-heat-treated for billing purposes and that the billed units are per 150 I.U.
2. The Pharmacy Department should meet with the ED Physicians to ensure that documentation of “contact with suspected exposure to rabies from <type of animal>” is associated with the initial visit as well as subsequent visits so that the claim isn’t inadvertently billed as a preventive immunization. Patients who are immunocompromised should have their immune status clearly documented in the medical record if they return for a 5th dose of vaccine on Day 28.
3. Coders should query physicians if incomplete documentation is in the record, (e.g. “Patient has returned for second dose of rabies vaccine) to ensure that the correct diagnosis code indicating exposure is included in the claim.
4. Pharmacy and Revenue Integrity should explore patient assistance programs that cover some rabies vaccine and rabies immune globulin when appropriate.
