J4 MAC Issues Billing Instructions for Denosumab
Beginning Jan. 1, 2012, a new HCPCS Level II code has been assigned to the drug denosumab. Formally C9272 Injection, denosumab, 1 mg, denosumab should now be reported with J0897 (description remains the same).
The drug denosumab has two brand names with two different indications:
Prolia® – indicated to treat osteoporosis in women after menopause.
Xgeva® – indicated for the prevention of skeletal-related events in patients with bone metastases from solid tumors.
When billing Prolia for patients with postmenopausal osteoporosis, TrailBlazer Health Enterprises instructs providers to report ICD-9 diagnosis code 733.01 Senile osteoporosis on the claim. And when billing Xgeva for patients with bone metastases from solid tumors, providers should report ICD-9 code 198.5 Bone and bone marrow on the claim.
TrailBlazer, Medicare administrative contractor for jurisdiction 4 (J4-MAC), further instructs providers to indicate in the comment section of the claim which drug is being administered, Prolia or Xgeva.
Remember: The medical record must clearly demonstrate the patient has been diagnosed as indicated on the claim.
“Utilizing the recommended diagnosis code in situations where medical records do not support the reported diagnosis is not appropriate,” TrailBlazer warns.