Oncology & Hematology Coding Alert

Question: A Medicare patient is receiving Firmagon and Prolia. If he gets these on the same day, we have been billing J9155, J0897, 96402, and 96372 with modifier 59. Medicare is not paying on the 96402, but the codes are not bundled according to the latest edits I've seen.

I'm reporting diagnoses M85.9, C61, and Z79.899. What is the correct way to bill these injection codes?

Wisconsin Subscriber

Answer: As a starting point, you are reporting the correct procedure and HCPCS codes:

• J9155 – Injection, degarelix, 1 mg
• J0897 – Injection, denosumab, 1 mg
• 96402 – Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic 
• 96372 – Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular with modifier 59 (Distinct procedural service).

The problem might lie with your diagnosis codes, and how you are linking them to the procedure/service. You should link only the codes that pertain to each service and medication supply specifically.

It appears that you are linking all your diagnosis codes to each line item. The Prolia and the 96372 should link only to the code(s) that requires the Prolia, such as M85.88 (Other specified disorders of bone density and structure, other sites) or M85.89 (Other specified disorders of bone density and structure, multiple sites) as long as one of the codes are supported by the medical record documentation. If the information is not present in the record to select a more specific ICD-10-CM code, query the physician to provide the information in the record.

Warning: Avoid the use of diagnosis code M85.9 (Disorder of bone density and structure, unspecified) as this code is "unspecified" when possible. Since 2017, most insurers will not reimburse for unspecified ICD-10-CM diagnostic codes. The Firmagon should link to the C61 (Malignant neoplasm of prostate), as it is used as a treatment for cancer of theprostate. Another diagnosis that may be linked to Prolia in this scenario is Z79.899 (Other long term [current] drug therapy). Again, the documentation must support the code you select.

Resubmit the claim following these procedure/diagnosis links and supporting documentation, and you could see better results.