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Prolia injection

  1. #1
    Default Prolia injection
    Medical Coding Books
    Are any physician practices billing Medicare and getting paid for Prolia injections (aka denosumab)? If so, how much is Medicare allowing for your area?

    Becky, CPC

  2. #2
    Location
    Cleveland/Akron OH
    Posts
    33
    Default
    I am billing it (Ohio) and they are paying. Bill out: J3490 w NDC #55513071001. They are allowing $825 & paying the 80% $660. Almost all our payers are paying & if they don't Prolia Plus will fight it.

  3. #3
    Default
    Just the info I was looking for. Thank you!!

    Becky

  4. Default Prolia billing
    What code is used for the administration for Osteoporosis?

  5. #5
    Location
    WEST PALM BEACH
    Posts
    10
    Default prolia
    our PCP offices were billing the prolia under J3490 and 96372, a few months ago they were told by the Prolia rep to change to J3590 and 96401. FL medicare pays the same for the J code, but doubles the reimbursement for the 96401. I wanted to know if this is OK. The HCPCS books still says Prolia should be J3490. Does anybody have an answer to this question. Should I tell my offices to go back to the J3490 and 96372?

  6. Unhappy Billing Specialist
    We have been billing Medicare here in Florida for the Prolia injection and get nothing but denials. I have even sent the information necessary for payment and they still deny, anyone have any suggestions on what the issue could be? We use J3490 with 96372. In box 19 we put Denosumab 60mg sc inj then the NDC code. We can't seem to get it paid. Any suggestions?:

  7. #7
    Default I would try calling your local rep
    and see what you find out. Please post the info when you find out

  8. #8
    Location
    Springfeild, MO
    Posts
    10
    Default Prolia
    In my Coders' Desk Reference for Procedures book the defination for code range 96401-96402 is as follows..
    The physician or supervised assistant prepares and administers non-hormonal medication to combat diseases such as [B]malignant neoplasms or microorganisms. [B] These codes apply to medication injected under the skin (subcutaneous) or into a muscle (intramuscular) often in the arm or leg. Report 96402 for a hormanal medication administered to combat diseases such as malignant neoplasms or microorganisms.

  9. #9
    Default
    Quote Originally Posted by donna.lowery2010@gmail.com View Post
    We have been billing Medicare here in Florida for the Prolia injection and get nothing but denials. I have even sent the information necessary for payment and they still deny, anyone have any suggestions on what the issue could be? We use J3490 with 96372. In box 19 we put Denosumab 60mg sc inj then the NDC code. We can't seem to get it paid. Any suggestions?:
    We bill Medicare here in Virginia for Prolia and are receiving reimbursement. What ICD-9 code are you using? Perhaps that could be the issue. We use the same J-code and admin code you have listed above and put the info in box 19 as you have stated also. We use ICD-9 733.01 as this is the diagnosis documented in the chart that warrants the Prolia.

    I hope this info helps!
    Teresa Collins, CPC

  10. Default
    Prolia has been such a pain for us as well, but I do have to say that our Prolia rep is great and has helped us get reimbursed every step of the way. If we haven't gotten reimbursed by the insurance company, Prolia has stepped in to help fight the fight and/or the patient has qualified for the assistance program. We are in Florida and were actually told by our rep to bill J3590 and 96401. They stated we could bill the 96401 as Prolia was a biological drug and was covered under this code.

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