Coding Resource - synagishcp.com

1 Coding ResourceNational Drug Code (NDC)1 Current Procedural Terminology 2 Healthcare Common Procedure Coding System3 SYNAGIS (palivizumab) is a respiratory syncytial virus (RSV) F protein inhibitor monoclonal antibody indicated for the prevention of serious lower respiratory tract disease caused by RSV in children at high risk of RSV Resource lists codes that may be useful for billing and reimbursement for SYNAGIS. It is important to note that the codes identified below are examples only. Each provider is responsible for ensuring that all Coding is accurate and documented in the medical record based on the condition of the patient.

2 The use of the following codes does not guarantee NDC 50-mg vial66658-230-01100-mg vial66658-231-01 CodeDescription S9562 Home injectable therapy, palivizumab, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diemCodeDescription Supply and administration of RSV immunoprophylaxis90378 Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscularDosage11-digit NDC50-mg vial66658-0230-01100-mg vial66658-0231-01 INDICATIONSYNAGIS, 50 mg and 100 mg for injection, is indicated for the prevention of serious lower respiratory tract disease caused by respiratory syncytial virus (RSV) in pediatric patients.

3 With a history of premature birth ( 35 weeks gestational age) and who are 6 months of age or younger at the beginning of RSV season with bronchopulmonary dysplasia (BPD) that required medical treatment within the previous 6 months and who are 24 months of age or younger at the beginning of RSV season with hemodynamically significant congenital heart disease (CHD) and who are 24 months of age or younger at the beginning of RSV seasonLIMITATIONS OF USEThe safety and efficacy of SYNAGIS have not been established for treatment of RSV disease. CONTRAINDICATIONSP revious significant hypersensitivity reaction to SAFETY INFORMATIONH ypersensitivity Reactions: Anaphylaxis and anaphylactic shock (including fatal cases) and other severe acute hypersensitivity reactions have been reported.

4 Permanently discontinue SYNAGIS and administer appropriate medication if such reactions occur. Please see additional Important Safety Information on page 4. Click here for full Prescribing Information for SYNAGIS, including Patient Academy of Pediatrics; GA=gestational age; ICD-10-CM=International Classification of Diseases, 10th Revision, Clinical Modification; NPA=National Perinatal Association.*NPA guidelines recommend SYNAGIS for patients with additional provider-identified risk see additional Important Safety Information on page 4. Click here for full Prescribing Information for SYNAGIS, including Patient DYSPLASIA/CHRONIC LUNG DISEASE OF dysplasia originating in the perinatal chronic respiratory diseases originating in the perinatal chronic respiratory disease originating in the perinatal periodPREMATURITY ( 35 WEEKS GA)

5 Immaturity of newborn, GA <23 completed newborn, GA 29 completed immaturity of newborn, GA 23 completed newborn, GA 30 completed immaturity of newborn, GA 24 completed newborn, GA 31 completed immaturity of newborn, GA 25 completed newborn, GA 32 completed immaturity of newborn, GA 26 completed newborn, GA 33 completed weeks* immaturity of newborn, GA 27 completed newborn, GA 34 completed weeks* newborn, GA 28 completed newborn, GA 35 completed weeks*HEMODYNAMICALLY SIGNIFICANT CONGENITAL HEART , congenital malformations of cardiac chambers and failure, malformation of cardiac chambers and connections, hypertension of septal arterial septal outlet right septal outlet left Tetralogy of ventriculoarterial septal inlet Other congenital malformations of cardiac atrioventricular malformation of cardiac septum, of atrial valve atresiaDiagnosis Codes1,4-6 Label Guidance AAP Guidance NPA GuidelinesPATIENT for prophylactic immunotherapy for RSVHEMODYNAMICALLY SIGNIFICANT CONGENITAL HEART DISEASE (cont d)

6 Pulmonary valve aortic pulmonary valve malformation of aorta congenital malformations of pulmonary Absence and aplasia of tricuspid of s aneurysm of right heart dilation of congenital malformations of tricuspid aortic malformation of tricuspid valve, aortic stenosis of aortic aortic insufficiency of aortic origin of subclavian mitral congenital malformations of mitral of pulmonary left heart of pulmonary congenital malformations of aortic and mitral of pulmonary pulmonary arteriovenous congenital malformations of pulmonary infundibular congenital malformations of other great subaortic malformation of great arteries.

7 Of coronary stenosis of vena Congenital heart left superior vena specified congenital malformations of anomalous pulmonary venous ductus anomalous pulmonary venous of pulmonary venous connection, of aortic congenital malformations of great atresia of malformation of great vein, unspecified Diagnosis Codes (cont d)1,4-6 Label Guidance AAP Guidance NPA GuidelinesPlease see additional Important Safety Information on page 4. Click here for full Prescribing Information for SYNAGIS, including Patient more information, call SYNAGIS CONNECT at 1-833-SYNAGIS (1-833-796-2447), Monday through Friday 8 am to 8 pm ET, or visit for additional : 1.

8 SYNAGIS [prescribing information]. Waltham, MA: Sobi, Inc. 2. American Medical Association. CPT 2020 Professional Edition. Chicago, IL: American Medical Association; 2020. 3. HCPCS Quarterly Update. Centers for Medicare & Medicaid Services website. Accessed June 27, 2022. 4. 2023 ICD-10-CM. Centers for Medicare & Medicaid Services website. Accessed June 27, 2022. 5. American Academy of Pediatrics Committee on Infectious Diseases; American Academy of Pediatrics Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection.

9 Pediatrics. 2014;134(2):415-420. 6. Goldstein M, Phillips R, DeVincenzo JP, et al. National Perinatal Association 2018 Respiratory Syncytial Virus (RSV) Prevention Clinical Practice Guideline: an evidence-based interdisciplinary collaboration. Neonatology Today. 2017;12(10) is a registered trademark of Arexis AB c/o Swedish Orphan Biovitrum AB (publ)SYNAGIS CONNECT is a registered trademark of Arexis AB c/o Swedish Orphan Biovitrum AB (publ) 2022 Swedish Orphan Biovitrum. All rights reserved. PP-10898 ( ) 07/22 IMPORTANT SAFETY INFORMATION (cont d)Coagulation Disorders: SYNAGIS should be given with caution to children with thrombocytopenia or any coagulation disorder.

10 RSV Diagnostic Test Interference: Palivizumab may interfere with immunological-based RSV diagnostic tests, such as some antigen detection-based assays. Serious Adverse Reactions: The most common serious adverse reactions occurring with SYNAGIS are anaphylaxis and other acute hypersensitivity reactions. Most Common Adverse Reactions: The most common adverse reactions are fever and Experience: Severe thrombocytopenia and injection site reactions have been identified during post approval use of SYNAGIS. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.