# Prolia the new osteoporosis drug



## DebbiePottsEngland (Feb 8, 2011)

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.

thanks


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## Teresa Collins (Feb 8, 2011)

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!


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## DebbiePottsEngland (Feb 8, 2011)

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.
thanks


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## Teresa Collins (Feb 8, 2011)

Yes, Medicare allows $874.50.


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## AAbbott63 (Feb 8, 2011)

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.


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## DebbiePottsEngland (Feb 8, 2011)

thanks for the help.  you guys are great.


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## yankeegirl0919 (Feb 8, 2011)

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


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## yankeegirl0919 (Feb 8, 2011)

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


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## yankeegirl0919 (Feb 8, 2011)

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


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## DebbiePottsEngland (Feb 8, 2011)

C9292 and all Codes are for OPPS purposes only


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## yankeegirl0919 (Feb 8, 2011)

i am so sorry, i went to take a call and while i was on the phone, i realized i was giving you my opps information..please disregard my know-it-all posts...i was trying to be helpful and instead, i put my foot in my mouth...i'm sure they'll have a real code for you guys one day


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## DebbiePottsEngland (Feb 8, 2011)

Thank you all for your input.  I appreciate the fact that you gave an opinion.


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## rross (Feb 11, 2011)

I work in an oncology clinic and am curious as to what administration code have you been using?  We have been using 96401, but was recently told to use 96549- unlisted chemo procedure.. Is that correct?


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## DebbiePottsEngland (Feb 11, 2011)

we are not using it for chemo and I was not aware that it was a chemo drug.  We are using it for osteoporosis, If I remember correctly.  As of now we have not started using it.  they are thinking about it.  I would like to know what you are using it for. and if you have literature that you can share.


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## Teresa Collins (Feb 11, 2011)

DebbiePotts said:


> we are not using it for chemo and I was not aware that it was a chemo drug.  We are using it for osteoporosis, If I remember correctly.  As of now we have not started using it.  they are thinking about it.  I would like to know what you are using it for. and if you have literature that you can share.



The Prolia injection is for osteoporosis.  We have some literature that was given to us by the pharmaceutical rep that I will be happy to email to you.  If you are interested in it, please provide me your email address and I'll send it to you.

Thanks!


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## DebbiePottsEngland (Feb 11, 2011)

dpotts@dicksonmd.com
Thanks I appreciate it.


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## rross (Feb 11, 2011)

Our physicians have been using the Xgeva in lieu of Zometa for those patients who have developed bone mets.


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## hopepg (Feb 15, 2011)

Anyone have experience billing Prolia to Trailblazer/Medicare? 
We've filed using J3490 & included the 60MG dosage & NDC in the correct loop/segments of the claim. We continue to get denied for "missing/incomplete/invalid procedure code and/or modifier"
Please any help/insight would be much appreciated. 
Thanks!


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## Teresa Collins (Feb 16, 2011)

Yes, we bill Prolia to Trailblazer Medicare using J3490 and put "Prolia subcutaneous 60 mg dose administered "  along with the NDC number and have had success in getting the claims paid.  I did call our software vendor; however, prior to submitting the claim to be certain that the field where I was entering the detailed info would indeed be in the correct loop.  We have given 2 Prolia injections to Trailblazer Medicare patients and have gotten both claims paid.  

I hope this information is of help to you!


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## hopepg (Feb 16, 2011)

Thank you very much for the reply. I think what we've been missing is specifically saying Prolia in our comment. I appreciate the help!
Hope


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## Teresa Collins (Feb 17, 2011)

You are welcome!


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## tammieo (Mar 3, 2011)

*Can anyone tell me if BCBS and Aetna are covering the prolia*



DebbiePotts said:


> 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.
> 
> thanks



Can anyone tell me if BCBS and Aetna are covering the prolia?


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## sandraebert (Mar 12, 2011)

*Sandra Ebert*

We gave a Prolia injection in August 2010 and still having trouble with
Medicare.  Does anyone have a Medisoft medical computer program?
Can't seem to get strength and dosage in.  Tried consultants, vendors etc.


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## Tammykirsch (May 17, 2011)

*Prolia*

We are using C9272(Denosumab 60mg/ml)


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## reddel (May 18, 2011)

Did anyone ever post which admin code is used with Xgeva?


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## cajigasa (May 19, 2011)

*Prolia*

code for prolia is C9272  60 units


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## cajigasa (May 19, 2011)

*Xgeva*

J3490, J350, depending on the payor or C9272 with 120 mg


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## missett (Jun 2, 2011)

*Prolia*

Could someone enlighten me on code C9272?  Can this code be used if given in the office or is this code only to be used if patient in out patient hospital setting?
Thanks


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## gsmith (Jun 9, 2011)

*Prolia*

Code C9272 is a pass-through code and should only be used by hospital outpatient departments.  If you are billing in an office setting, use J3590 or J3490.


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## mcr454 (Jun 9, 2011)

aabbott said:


> 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.



xgeva is only for cancer related conditions, not "regular" osteoporosis such as senile osteoporosis in which case the larger reimbursement is not valid.  FCSO recognizes the J code and reimbursement is in the $860's- also include your office injection code for the office settings


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