Synagis Injections Billing

Synagis, the only monoclonal antibody approved by the U.S. Food and Drug Administration (FDA) to help prevent an infectious disease, has limited TRICARE coverage and always requires authorization. Synagis is indicated for the prevention of serious lower respiratory tract disease caused by Respiratory Syncytial Virus (RSV) in children at high risk of RSV. You should follow the guidelines of the American Academy of Pediatrics for the treatment of RSV, which can be found on the organization’s Web site at www.aap.org.

RSV is the most common respiratory infection found in infancy or childhood that circulates in the Northern Hemisphere. Approximately one-half of all infants are infected with RSV during the first year of life, and nearly all children have been infected at least once by the time they reach their second birthday. Children born prematurely, as well as those with chronic lung disease or with congenital heart disease (CHD), are at high risk for severe disease and hospitalization due to RSV. The virus may also cause severe illness in other high-risk groups such as the elderly, those with underlying respiratory or cardiac disease, and those with compromised immune systems (e.g., bone marrow transplant patients).

Please use the Synagis form in the Clinical Information section under the Find a Form tab of www.triwest.com/provider to request prior authorization for Synagis. The Synagis form supplements the regular TRICARE Patient Referral/Authorization Form. Here is a chart that indicates what code to use depending on the place of service.

Place of Service	Code
Physician’s office	CPT code 90378
Outpatient setting	HCPCS code C9003
Home	Appropriate J code if available or J3490 with the proper National Drug Code (NDC)

Providers will be reimbursed at 95 percent of average wholesale price (AWP), less any contractual discount.

Published Date: 09/16/2009