Urology 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 medical necessity codes for the service.

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).

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

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