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J4 MAC Issues Billing Instructions for Denosumab

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  • In Billing
  • December 30, 2011
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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.

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No Responses to “J4 MAC Issues Billing Instructions for Denosumab”

  1. Linnell Heinbockel says:

    I have a new provider and when it came time for my Prolia injection, they made me buy the Prolia at CVS Pharmacy, shipped to me in a chilled container), and I was instructed to keep it overnight in my fridge, and bring it into the office, where the nurse injected it. CVS charged me a $478 co-pay, which was a shock since my previous provider had arranged to have the Prolia at her office and those injections cost me nothing (as far as out-of-pocket cost). Anyway, I just received the Medicare billing from my new provider — which reflects J0897 ($2,580) and 26372 ($98). Most of this is covered, but something seems amiss.