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Tiffanynora

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Question about diagnosis for patients that are seen in infusion clinics for the "Prolia (denosumab)" injection.
I am being instructed to code Z51.15 - Encounter for antineoplastic immunotherapy as the Primary Diagnosis following the providers diagnosis (M81.0) for these encounters for when the patient is seen for their injection.

Should I be including the "Z51.12" DX code?
I am not finding any information to support billing this way.

My sources of information: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52399&ver=50&=
https://www.proliahcp.com/-/media/T...162_82995_Prolia-Billing-and-Coding-Guide.pdf
 

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Who is instructing you to use the Z51.12? The provider or the payer? Does the patient also have a neoplastic condition or are they strictly being treated for age-related osteoporosis?

I would not use a Z51 code for a Prolia injection for age-related osteoporosis. The code book specifically says for a nonneoplastic condition to code to the condition.

To the best of my knowledge, we don't use a Z51 code for Prolia at my workplace. (That being said, I'm not the one who codes those accounts - I work specifically with the radiation therapy.)

If a specific payer was requiring it, we might bill it for that payer, but not across all payers.
 
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I wonder if there's some confusion because the J0897 for Prolia should really be for Xgeva J3489...that would allow a z51 code, correct?
 
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debi_broone89@yahoo.com said:
what admin code do you use for Prolia? is it 96401 or 96372?
Click to expand...
I actually just had a philosophical discussion with several other coders regarding this. Prolia is not primarily an anti-neoplastic drug but a monoclonal antibody.
Codify gives this information about 96401:
Clinical Responsibility
The provider discusses the risks and benefits of the chemotherapy with the patient and counsels the patient on the side effects of the drug. After informed consent, the provider administers nonhormonal, antineoplastic chemotherapy drugs subcutaneously or intramuscularly to the patient. Drugs administered during this service include nonradionuclide antineoplastic drugs, monoclonal antibody agents and other biologic response modifiers, and other antineoplastic agents, excluding hormonal drugs.

This indicates that 96401 may also be used for monoclonal antibody drugs, like Prolia.
However, some payors have explicitly stated that Prolia should be billed with 96372 and not 96401.
For carriers that have such a policy, we bill 96372. For carriers that do not have a policy, we use 96401.
My PERSONAL opinion is that if Prolia is being administered as a therapeutic or prophylactic treatment, it should be 96372 regardless of payor.
 
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csperoni said:
I actually just had a philosophical discussion with several other coders regarding this. Prolia is not primarily an anti-neoplastic drug but a monoclonal antibody.
Codify gives this information about 96401:
Clinical Responsibility
The provider discusses the risks and benefits of the chemotherapy with the patient and counsels the patient on the side effects of the drug. After informed consent, the provider administers nonhormonal, antineoplastic chemotherapy drugs subcutaneously or intramuscularly to the patient. Drugs administered during this service include nonradionuclide antineoplastic drugs, monoclonal antibody agents and other biologic response modifiers, and other antineoplastic agents, excluding hormonal drugs.

This indicates that 96401 may also be used for monoclonal antibody drugs, like Prolia.
However, some payors have explicitly stated that Prolia should be billed with 96372 and not 96401.
For carriers that have such a policy, we bill 96372. For carriers that do not have a policy, we use 96401.
My PERSONAL opinion is that if Prolia is being administered as a therapeutic or prophylactic treatment, it should be 96372 regardless of payor.
Click to expand...
Thank you, have to discuss with the auditor👍
 
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csperoni said:
I actually just had a philosophical discussion with several other coders regarding this. Prolia is not primarily an anti-neoplastic drug but a monoclonal antibody.
Codify gives this information about 96401:
Clinical Responsibility
The provider discusses the risks and benefits of the chemotherapy with the patient and counsels the patient on the side effects of the drug. After informed consent, the provider administers nonhormonal, antineoplastic chemotherapy drugs subcutaneously or intramuscularly to the patient. Drugs administered during this service include nonradionuclide antineoplastic drugs, monoclonal antibody agents and other biologic response modifiers, and other antineoplastic agents, excluding hormonal drugs.

This indicates that 96401 may also be used for monoclonal antibody drugs, like Prolia.
However, some payors have explicitly stated that Prolia should be billed with 96372 and not 96401.
For carriers that have such a policy, we bill 96372. For carriers that do not have a policy, we use 96401.
My PERSONAL opinion is that if Prolia is being administered as a therapeutic or prophylactic treatment, it should be 96372 regardless of payor.
Click to expand...
My personal opinion agrees with your personal opinion. CPT manual states that the chemo admin codes may be used with certain monoclonal antibody agents...[because they] require physician or other qualified healthcare professional work and/or clinical staff monitoring well beyond that of therapeutic drug agents because the incidence of severe adverse patient reactions are typically greater...commonly, these services entail significant patient risk and frequent monitoring.

I'm not clinical, but I haven't seen the above with Prolia and it's not addressing a malignancy.
 
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rachaelwilleford said:
My personal opinion agrees with your personal opinion. CPT manual states that the chemo admin codes may be used with certain monoclonal antibody agents...[because they] require physician or other qualified healthcare professional work and/or clinical staff monitoring well beyond that of therapeutic drug agents because the incidence of severe adverse patient reactions are typically greater...commonly, these services entail significant patient risk and frequent monitoring.

I'm not clinical, but I haven't seen the above with Prolia and it's not addressing a malignancy.
Click to expand...
When I used to get auths for Prolia it was a real pain! Especially since the same drug Denosumab was given as Xgeva in Neoplastic Bone Cancers, just in higher doses more frequently.. Who knows...I just work here is my usual answer.

P.S. I spent high school years in Lafayette!!
 
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Lewis16 said:
When I used to get auths for Prolia it was a real pain! Especially since the same drug Denosumab was given as Xgeva in Neoplastic Bone Cancers, just in higher doses more frequently.. Who knows...I just work here is my usual answer.

P.S. I spent high school years in Lafayette!!
Click to expand...
Prolia = 60 mg. Xgeva = 120 mg. Same drug, just different doses.

I spent a few years in Oklahoma myself. I actually started my revenue cycle journey in Lawton.
 
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