#1 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.
Full Answer
What is Prolia for osteoporosis?
• Prolia is the first and only prescription medicine for postmenopausal osteoporosis that is a shot given 2 times a year in your doctor’s office You should take calcium and vitamin D as your doctor tells you to while you receive Prolia For dates of service 01/01/2 012 and forward :
Who are the administrative contractors for Medicare?
Medicare Administrative Contractors Since Medicare’s inception in 1966, private health care insurers have processed medical claims for Medicare beneficiaries. Originally these entities were known as Part A Fiscal Intermediaries (FI) and Part B carriers.
What is the recommended dose of denosumab (Prolia™) for osteoporosis?
The recommended dose of Denosumab (Prolia™) for the treatment of osteoporosis in postmenopausal women is 60 milligrams (mg) subcutaneously once every 6 months, plus calcium 1000 mg orally once daily and at least vitamin D 400 international units orally once daily. Administer Denosumab (Prolia™) via subcutaneous injection in the upper arm, the upper
What is the CPT code for prophylactic injection?
The administration of the product should be billed using CPT code 96372, (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular). The list below is not an all-inclusive list and may be subject to further revision.
What administration code is used for Prolia?
The administration of denosumab, when billed, should be billed using the therapeutic administration code 96372 (Therapeutic prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.
Does Medicare Part B pay for Prolia injections?
Injectable Drugs Coverage Medicare Part A or Medicare Part B will pay for a portion of the cost of osteoporosis medications delivered intravenously or by injection. These medications may include ibandronate (Boniva), zoledronic acid (Reclast), denosumab (Prolia) and sometimes calcitonin (Miacalcin).
How is Prolia billed to Medicare?
The majority of commercial and Medicare plans cover Prolia®. The list price for Prolia® is $1,434.14* ,† per treatment every six months. Most patients do not pay the list price. Your actual cost will vary.
What part of Medicare covers Prolia?
For those who meet the criteria prescribed above, Medicare Part B covers Prolia. If you don't meet the above criteria, your Medicare Part D plan may cover the drug. GoodRx reports that 98% of surveyed Medicare prescription plans cover Prolia. With Medicare Part D coverage, you're likely to pay coinsurance or a copay.
Does Medicare require prior authorization for Prolia?
All requests for Xgeva (denosumab), Prolia (denosumab) require a prior authorization and will be screened for medical necessity and appropriateness using the criteria listed below.
Do Medicare Advantage plans cover Prolia?
Yes! 99% of Medicare Advantage plans and Medicare Part D plans cover Prolia.
What diagnosis covers Prolia?
Prolia® is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy.
What is the ICD 10 code for long term use of Prolia?
Long term (current) use of bisphosphonates Z79. 83 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM Z79. 83 became effective on October 1, 2021.
What code is J0897?
HCPCS code J0897 for Injection, denosumab, 1 mg as maintained by CMS falls under Drugs, Administered by Injection .
What tier is Prolia?
What drug tier is Prolia typically on? Medicare prescription drug plans typically list Prolia on Tier 4 of their formulary. Generally, the higher the tier, the more you have to pay for the medication.
How is Prolia administered?
Denosumab injection comes as a solution (liquid) to be injected subcutaneously (under the skin) in your upper arm, upper thigh, or stomach area. It is usually injected by a doctor or nurse in a medical office or clinic. Denosumab injection (Prolia) is usually given once every 6 months.
Is Prolia on the PBS?
The PBAC recommended listing of denosumab as an Authority required (Streamlined) benefit as the sole PBS-subsidised anti-resorptive agent for osteoporosis to include both male and female patients....Recommended listing.Condition/Indication:OsteoporosisRestriction:Authority required (STREAMLINED)3 more rows
What is Prolia used for?
Prolia® is a prescription medicine used to treat osteoporosis (thinning and weakening of bone) in women after menopause who are at high risk for fracture, meaning women who have had a fracture related to osteoporosis, or who have multiple risk factors for fracture. [1]
Who is Charla Prillaman?
Charla Prillaman, CPC, CPCO, CPMA, CPC-I, CCC, CEMC, has more than 30 years’ experience in coding, compliance, and billing for physician practices. She has experience in an academic setting as well as private practice. Prillaman’s compliance experience includes auditing, IRO work, development and implementation of practice compliance plan, and writing policy and procedure. She provides post audit support at Audit Services Group.
Can you cite chemo drugs under Medicare?
The drugs cited are not intended to be a complete list of drugs that may be administered using the chemotherapy administration codes. Local carriers may provide additional guidance as to which drugs may be considered to be chemotherapy drugs under Medicare.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.
Article Guidance
The Medicare Administrative Contractor has determined in review of submitted claims that there is inappropriate use of CPT codes 96401-96549 for chemotherapy and other highly complex drug or highly complex biologic agent administration.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
Where to administer Prolia?
Administer Denosumab (Prolia™) via subcutaneous injection in the upper arm, the upper. thigh, or the abdomen. Denosumab (Prolia™) is supplied in a single-use prefilled syringe with a safety guard or in a single-use vial.
How does Prolia work?
Prolia works by targeting a molecule that the bone-removing cells need in order to work. Important Safety Information.
Is Prolia approved for multiple myeloma?
Limitations: • Denosumab (PROLIA™) is contraindicated in patients with hypocalcemia. • Denosumab (PROLIA™) is contraindicated in patients with pregnancy. • Denosumab (Xgeva™) is not approved for patients with multiple myeloma or other cancers of the blood. Coding Guidelines:
Is denosumab approved by Medicare?
The FDA has approved the use of denosumab (PROLIA™) and (Xgeva™). Medicare has determined under Section 1861 (t) that this drug may be paid when it is administered incident to a physician’s service and is determined to be reasonable and necessary.
Does Prolia help with bone loss?
Prolia has helped stop most of the bone-removing cells from getting to the bone and causing bone loss. Why Prolia is different. • Prolia is the first and only prescription medicine for postmenopausal osteoporosis that is a shot given 2 times a year in your doctor’s office.