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Wiki 96401 and Prolia

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ebrodsky

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Medicare contractor NGS states that CPT code 96401 may be used for the administration of Prolia/Denosumab (HCPCS code J0897). But 96401 is for chemotherapy administration and Prolia is now an accepted treatment for certain cancer types. Does anyone think it's appropriate to use 96401 when Prolia is used for treatment of osteoporosis?
 
Medical Policies (LCD's) don't always make 100% sense to us, but it's their guidelines we must follow them if we want paid. It's the best description of what service is being performed, it's more than a the simple IM injection 96372.

Just watch your diagnosis as they are tricky and may require multi-diagnosis reporting depending on your situation.
 
Prolia (Denosumab) Administration Code

It's always a great idea to check your local MAC policies, but also as this article indicates, other payor policies as well. My local MAC (New Hampshire) indicates "The administration of DENOSUMAB, when billed, should be billed using the therapeutic administration code 96372". This article effective date is 10/1/2015.

https://www.aapc.com/blog/31464-prolia-denosumab-j0897-administration/
 
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