Wiki Injections

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KaylaRieken

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Waukee, IA
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Medicare patient is receiving Firmagon and Prolia. If they get these on the same day, we have been billing J9155, J0897, 96402, and 96372.59. Medicare is not paying on the 96402, but they are not bundled. How is everyone else billing these injection codes out?
 
96372 is a column 2 code to 96402..maybe they won't unbundle ??

Have you been getting paid from Medicare on the Prolia ? And if so, what diagnosis codes are you using ?

NGS Medicare in WI has denied our claims for it

Thanks
Rebecca
 
what dx codes are you using and how are you linking them to the injection codes and drug codes.
 
you dx codes and linkage may be the problem. you should link only the medical necessity for the service not all codes on the claim. it looks like you are linking all your dx codes to each line item. The prolia and the 96372 should link only to the code that requires the prolia and FYI it should not be M85.9 as that code is unspecified, and prolia does not treat prostate cancer. you need better medical necessity. the Firmagon should link only to the C61 as that is what it treats. I see no need for the Z79.899 in this scenario. It could be these dx codes and jhow you linked them are the root of the problem
 
The dx codes that I use are for the Firmagon C61, For the Prolia C61 and Z79.899 and for the injection codes I use C61. They are paying on everything but the 96402 injection code. Is everyone else getting paid on both injection codes?
 
Medicare LCD L33394 requires the use of the 3 dx codes for Prolia use in male patients w/ prostate cancer which we used on our claims and still getting denied..at a loss at to why
 
Which MAC are you in? Because for J5 MAC there is not a LCD and can be diagnosis pointer related.
 
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