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Prolia the new osteoporosis drug

  1. #1
    Default Prolia the new osteoporosis drug
    Medical Coding Books
    I have been looking for a HCPCS code for Prolia. It is a new drug and I am thinking I am going to have to use J3490 (unlisted code). I would appreciate any help.

    Debbie Potts England
    Lyles, TN 37098

  2. #2
    Yes, you will have to use J3490. Also list the name and dosage of the drug and NDC number. We administer Prolia and this is how we have to file the claims. Some insurance companies will request office notes as well.

    I hope this helps!
    Teresa Collins, CPC

  3. #3
    can you give me a Medicare allowable that you have received? I know that mine will not be the same but at least it will be an estimate.
    Debbie Potts England
    Lyles, TN 37098

  4. #4
    Yes, Medicare allows $874.50.
    Teresa Collins, CPC

  5. Default
    We are actually using the brand name Xgeva. We are using the J3590, unclassified biologic. Also, our Medicare allowed is $1744.68 per dose. Remember that one dose of denosumab is 120mg (1 vial = 120mg) and therefore you will only bill for one unit. So be sure to set up fee schedule based on that. I found a pdf file that was very helpful on the Amgen Assist website.

    Another note on the coding, we found out recently that Cahaba Medicare did not like the J3590 and requested the J9999 instead.

    I hope this helped.

  6. #6
    thanks for the help. you guys are great.
    Debbie Potts England
    Lyles, TN 37098

  7. Default
    the hcpcs code for denosumab is c9272..however, i only see this linked to prolia, not to xgeva..

  8. Default
    and, that's because xgeva wasn't approved until after the code was created..

  9. Default
    the reimbursement is 14.539 per mg so for prolia, bill 60 units and xgeva 120 units...i hope i'm being helpful

  10. #10
    C9292 and all Codes are for OPPS purposes only
    Debbie Potts England
    Lyles, TN 37098

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