CPT© Code: 90378
Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each
Criteria for Coverage
Synagis® (palivizumab) will be allowed monthly during the RSV season, October 19th – April 21st
.
Prior Authorization
Prior Authorization must be obtained through Health Information Designs by completing the online
form found at; http://hidesigns.com/ndmedicaid/pa-forms.html - choose Synagis Registration Form
The ND MMIS Service Authorization Number located on the approval letter must be entered on the
claim at the time of submission. Failure to do so will result in claim denial.
Coding and Billing Instruction
CPT© 90378 must be billed electronically via an 837P transaction with the correlating NDC code for
the Synagis® administered.
Synagis® is available in both 50 mg and 100 mg vials. Multiple vial dosages should be reported with
the most accurate combination to reflect the actual amount of drug administered. Each unique NDC
must be reported on a separate line on the 837P with the correlating number of HCPCS units.
Effective for dates of service on or after 10/19/2018 standard National Correct Coding Initiative
(NCCI) Procedure to Procedure (PTP) editing will be applied to the administration code (CPT 96372)
and Evaluation and Management (E/M) Service combination when rendered on the same date of
service by the same provider.


References:
https://www.nd.gov/dhs/services/medicalserv/medicaid/docs/cpt/synagis-coding-guidelines.pdf