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Prolia® (Denosumab – J0897) Administration

Prolia® (Denosumab – J0897)  Administration

By Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA
Have you ever had a conversation with someone whose knowledge you know is always spot-on, and he or she says something that sounds just plain wrong? This recently happened to me. How could Auditor A say that, so authoritatively? I recently provided different coding advice to a client after doing extensive research. I knew I was right!
My client had asked if CPT® 96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic or CPT® 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular is correct to report administration of Prolia®. CPT® 96401 is valued at approximately $75, and CPT® 96372 at approximately $25 (Medicare fee schedule). Clearly, this could be a compliance risk or a significant loss of revenue if the correct choice isn’t made.
Prolia® is a prescription medicine used to treat osteoporosis (thinning and weakening of bone) in women after menopause who are at high risk for fracture, meaning women who have had a fracture related to osteoporosis, or who have multiple risk factors for fracture.[1]
You may ask, why would this drug ever be reported using 96401? A coding “hint” that alerts us is the suffix “-mab,” which tells us the drug is a monoclonal antibody. We learn from CMS that administration monoclonal antibodies are reported with the chemotherapy administration code 96401.

Chemotherapy administration codes apply to parenteral administration of nonradionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers. The following drugs are commonly considered to fall under the category of monoclonal antibodies: infliximab, rituximab, alemtuzumb, gemtuzumab, and trastuzumab. Drugs commonly considered to fall under the category of hormonal antineoplastics include leuprolide acetate and goserelin acetate. The drugs cited are not intended to be a complete list of drugs that may be administered using the chemotherapy administration codes. Local carriers may provide additional guidance as to which drugs may be considered to be chemotherapy drugs under Medicare. [2]

Why would my trusted colleague say, “No, we have to use 96372?” When we talked, I pointed her to the references cited so far. She, in turn, took me to her local MAC, who says,

Denosumab may not be billed using a chemotherapy administration code. The administration of the product should be billed using CPT code 96372, (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular).[3]

We laughed (a good auditor always maintains a sense of humor), and realized that this is one of those coding questions that has more than one correct answer. We each looked up other payer guidance and found that one recommends reporting 964011 or 96372. Most payers agree with CMS and instruct us to report 96401.
The message to auditors, IMO, is two-fold. First, always keep an open mind and listen to others thoughts so that you, too, can learn when there is more than one “truth.” Secondly, always audit in the context of your payer and published instruction.  There are lots of instances where more than one answer may be correct.
[2] ; 30.D

Charla Prillaman
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Charla Prillaman, CPC, CPCO, CPMA, CPC-I, CCC, CEMC, has more than 30 years’ experience in coding, compliance, and billing for physician practices. She has experience in an academic setting as well as private practice. Prillaman’s compliance experience includes auditing, IRO work, development and implementation of practice compliance plan, and writing policy and procedure. She provides post audit support at Audit Services Group.

4 Responses to “Prolia® (Denosumab – J0897) Administration”

  1. Jenny says:

    is there an encounter icd 10 code we should also use for this

  2. Ruth Spelick says:

    I had a prolia injection last month. I was charged with a code of J0897 and 96372 for a total before insurance cost of $2925. I paid a copayment for the medication separately. My share of the cost was $528.27. I want to discuss this with my insurance company, but first I want to understand if these costs are acceptable and accurate. The person at the doctors office took 5 – 6 minutes to administer the medication. (one shot)

  3. Christy C. says:

    Ruth most of that cost is for the medication alone. It is quite an expensive medication. You can search cash pay prices at Most insurances are contracted to fill it though a specially to pharmacy who of course make it up to do paperwork, obtaining authorizations, filling and shipping the prescription. Probably $100 or less of that amount is the injection fee.
    Jenny it would be the diagnosis of either Osteoporosis w/ or w/o fracture (M81.0)

  4. Calvin C says:

    What does the time to administer the injection (5 seconds or 5 minutes) have anything to do with the effectiveness of Prolia injection J0897?