By Counterforce Health Team in Synagis (palivizumab) —

Coding That Helps Get Synagis (palivizumab) Approved in Pennsylvania with Blue Cross Blue Shield (ICD-10, HCPCS/J-Code, NDC)

Answer Box: Get Your Synagis Coding Right the First Time

Getting Synagis (palivizumab) approved by Blue Cross Blue Shield in Pennsylvania requires precise coding. Use HCPCS code 90378 (50 mg units), weight-based dosing at 15 mg/kg monthly, and supporting ICD-10 codes like P07.3X (premature birth) or Q24.9 (congenital heart defect). Submit through your BCBS provider portal with complete clinical documentation. First step today: Verify your patient's exact Blue Cross plan (Highmark vs. Independence) and download their current Synagis PA form from the provider portal.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for High-Risk Conditions
  3. Product Coding: HCPCS, J-Codes, and NDC
  4. Clean Request Anatomy
  5. Frequent Coding Pitfalls
  6. Verification with Blue Cross Blue Shield Resources
  7. Pre-Submission Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit Paths

Synagis (palivizumab) is always billed under the medical benefit as a physician-administered drug, never through pharmacy benefits. This distinction is crucial for Pennsylvania Blue Cross Blue Shield plans.

Medical Benefit Path (Standard)

  • HCPCS Code: 90378 (Respiratory syncytial virus, monoclonal antibody, 50 mg)
  • Claim Type: Professional (CMS-1500 or electronic equivalent)
  • Prior Authorization: Required through provider portal
  • Billing Entity: Physician office, clinic, or hospital outpatient

Why Not Pharmacy Benefit?

Unlike oral medications, Synagis requires intramuscular injection by healthcare providers. Blue Cross Blue Shield policies classify it as a medical benefit drug, making pharmacy claims inappropriate and likely to be denied.

Note: Some providers mistakenly attempt to bill through specialty pharmacies. This creates billing delays and denials. Always use medical benefit coding.

ICD-10 Mapping for High-Risk Conditions

Proper ICD-10 coding supports medical necessity for Synagis approval. Pennsylvania Blue Cross Blue Shield follows American Academy of Pediatrics guidelines for high-risk categories.

Primary Qualifying Conditions

Condition ICD-10 Code Documentation Requirements
Premature birth <29 weeks P07.30-P07.39 Birth certificate, NICU records
Chronic lung disease P27.1, J44.1 Pulmonology notes, oxygen requirements
Congenital heart disease Q20.0-Q28.9 Cardiology evaluation, hemodynamic significance
Immunodeficiency D80.0-D84.9 Immunology consultation, lab values

Supporting Diagnosis Codes

For RSV prevention context:

  • Z29.11 - Encounter for prophylactic immunotherapy
  • Z87.891 - Personal history of nicotine dependence (maternal smoking)
  • P22.0 - Respiratory distress syndrome of newborn

Documentation Language That Supports Coding

When documenting for Synagis approval, include specific phrases that align with ICD-10 criteria:

  • "Born at [X] weeks gestational age" (for P07.3X codes)
  • "Hemodynamically significant congenital heart disease" (for Q codes)
  • "Chronic lung disease requiring treatment in past 6 months" (for P27.1)
  • "High risk for severe RSV infection due to [condition]"

Counterforce Health helps clinicians identify the most compelling diagnostic language and evidence for complex approval cases like Synagis, where multiple risk factors may apply.

Product Coding: HCPCS, J-Codes, and NDC

Core Billing Information

HCPCS/CPT Code: 90378

  • Description: Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each
  • Unit Value: 1 unit = 50 mg of palivizumab
  • Billing Units: Total mg administered ÷ 50 mg (round up to nearest whole unit)

Dosing Mathematics

Standard Dose: 15 mg/kg body weight, administered monthly during RSV season

Example Calculation:

  • Patient weight: 7 kg
  • Required dose: 7 kg × 15 mg/kg = 105 mg
  • Vials needed: 105 mg requires 1 × 100 mg vial + 1 × 50 mg vial = 150 mg total
  • Billing units: 150 mg ÷ 50 mg = 3 units of 90378

NDC Requirements

Include the specific NDC number for the Synagis product administered:

  • 50 mg vial: Verify current NDC with your distributor
  • 100 mg vial: Verify current NDC with your distributor
Important: Synagis is being discontinued after December 31, 2025. Confirm product availability for the current RSV season and plan transitions to alternatives.

When Modifiers Apply

Modifier U1: Some Blue Cross Blue Shield plans require this modifier for dispensing fee reimbursement. Check your specific Pennsylvania plan requirements.

No modifier needed: Most standard Synagis administrations don't require modifiers when billed correctly under 90378.

Clean Request Anatomy

Example Prior Authorization Request

Patient Information:

  • Name: [Patient Name]
  • DOB: [Date] (Age: 8 months)
  • Member ID: [BCBS ID]
  • Weight: 7.2 kg

Diagnosis Codes:

  • Primary: P07.32 (Extremely low birth weight newborn, 1000-1249 grams)
  • Secondary: Z29.11 (Encounter for prophylactic immunotherapy)

Requested Service:

  • HCPCS: 90378
  • Quantity: 15 units (5 doses × 3 units per dose)
  • Frequency: Monthly during RSV season (November-March)
  • Total dose per administration: 108 mg (15 mg/kg × 7.2 kg)

Supporting Documentation:

  • Birth certificate showing 27 weeks gestational age
  • Current weight documentation
  • Pediatric pulmonology consultation
  • Previous RSV hospitalization records (if applicable)

Key Elements Blue Cross Blue Shield Reviews

  1. Patient meets high-risk criteria per AAP guidelines
  2. Appropriate dosing based on current weight
  3. Timing within RSV season (typically November 1 - March 31)
  4. No concurrent nirsevimab (Beyfortus) in same season
  5. Maximum 5 doses per RSV season

Frequent Coding Pitfalls

Unit Conversion Errors

❌ Wrong: Billing 1 unit for a 105 mg dose ✅ Correct: Billing 3 units (105 mg ÷ 50 mg = 2.1, rounded up to 3)

Mismatched Benefit Types

❌ Wrong: Submitting as pharmacy claim with NDC only ✅ Correct: Medical benefit claim with HCPCS 90378 and supporting NDC

Missing Start Date Documentation

❌ Wrong: "Patient needs Synagis for RSV season" ✅ Correct: "Patient born 27 weeks GA on [date], now 8 months old, requires RSV prophylaxis beginning November 2024"

Inappropriate Diagnosis Codes

❌ Wrong: Using only Z29.11 (prophylactic immunotherapy) without qualifying condition ✅ Correct: Primary qualifying diagnosis (P07.32) + secondary prophylaxis code (Z29.11)

Dose Timing Issues

Claims submitted for doses given less than 28 days apart will be denied. Pennsylvania Medicaid and many commercial plans enforce strict 28-day intervals between doses.

Verification with Blue Cross Blue Shield Resources

Provider Portal Access

Highmark Blue Cross Blue Shield (Western PA):

  • Access current PA forms through Highmark provider portal
  • Verify member eligibility and benefits
  • Check prior authorization status

Independence Blue Cross (Philadelphia area):

Policy Verification Steps

  1. Log into your BCBS provider portal
  2. Navigate to: Prior Authorization → Specialty Medications → Synagis
  3. Download: Current PA form and medical policy
  4. Verify: Coding requirements, documentation needs, submission methods
  5. Check: Any plan-specific modifiers or billing requirements
Tip: Pennsylvania Blue Cross Blue Shield plans update their Synagis policies annually. Always download the current year's forms and requirements.

Coverage Determination Tools

Use your plan's coverage determination tool to verify:

  • Formulary status for member's specific plan
  • Tier placement and cost-sharing
  • Prior authorization requirements
  • Quantity limits per RSV season

Pre-Submission Audit Checklist

Clinical Documentation ✓

  • Patient meets high-risk criteria (premature birth, CHD, CLD, or immunodeficiency)
  • Current weight documented within 30 days
  • Gestational age at birth confirmed
  • No concurrent RSV prophylaxis (Beyfortus) this season
  • Specialist consultation notes (cardiology/pulmonology if applicable)

Coding Accuracy ✓

  • HCPCS 90378 used (not J-codes or unspecified codes)
  • Units calculated correctly (total mg ÷ 50, rounded up)
  • ICD-10 codes match qualifying conditions
  • NDC matches product administered
  • Modifiers applied if required by plan

Submission Requirements ✓

  • Prior authorization completed before first dose
  • Provider portal used (not fax unless specified)
  • All attachments included (birth certificate, specialist notes)
  • Dose schedule documented (monthly, maximum 5 doses)
  • RSV season timing confirmed (November-March typically)

Administrative Details ✓

  • Member ID and demographics accurate
  • Prescriber information complete and current
  • Site of care appropriate (office, clinic, hospital outpatient)
  • Contact information for follow-up questions
  • Submission deadline met (varies by urgency)

From Our Advocates

We've seen Pennsylvania families successfully appeal initial Synagis denials by strengthening their ICD-10 documentation. One common pattern: adding specific gestational age details and specialist consultation notes to support the high-risk diagnosis. While every case is different, thorough clinical documentation paired with precise coding significantly improves approval odds.

Getting Synagis approved requires attention to coding details that Blue Cross Blue Shield reviewers specifically examine. Counterforce Health specializes in helping families and clinicians navigate these complex approval processes, turning insurance denials into successful appeals through targeted, evidence-backed strategies.

The key to success lies in matching your clinical documentation exactly to the coding requirements Pennsylvania Blue Cross Blue Shield uses for coverage decisions. When coding is precise and complete, approvals typically follow established timelines without unnecessary delays or appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage policies vary by specific Blue Cross Blue Shield plan and member benefits. Always verify current requirements through official insurer channels and consult with healthcare providers for medical decisions. For assistance with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department or seek help from qualified patient advocacy organizations.

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