Slbishop
New
Hello all,
Would anyone be able to help clarify the LCD policy for Prolia (J0897) Injection for Osteoporosis? I was told we needed an additional diagnosis besides having Osteoporosis, usually the patient cannot take oral Bisphosphonates, which would fall under Group 3 and/or 4 which does require 2 diagnosis, Osteoporosis and the reason for using Prolia. However If the physicians's order just states M81.0 Osteoporosis, can we accept that diagnosis alone, under Group 2? Groups 2 states, Treatment of Osteoporosis at High Risk for Fracture? Any assistance in this would be greatly appreciated. Thank you!
Would anyone be able to help clarify the LCD policy for Prolia (J0897) Injection for Osteoporosis? I was told we needed an additional diagnosis besides having Osteoporosis, usually the patient cannot take oral Bisphosphonates, which would fall under Group 3 and/or 4 which does require 2 diagnosis, Osteoporosis and the reason for using Prolia. However If the physicians's order just states M81.0 Osteoporosis, can we accept that diagnosis alone, under Group 2? Groups 2 states, Treatment of Osteoporosis at High Risk for Fracture? Any assistance in this would be greatly appreciated. Thank you!
Based on what I'm reading, M81.0 only is perfectly acceptable for patients at high-risk. We regularly report only M81.0 without problem. You only need a secondary or tertiary diagnosis in certain circumstances.