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Wiki Lupron & Prolia?

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reneedanielle22

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Charlotte, NC
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Does anyone know how to effectively bill for Lupron J9217 & Prolia/Xgeva J0897? Is it normal for your Patients to get stuck with $2,000 bill? Any advice/response would be appreciated. Thanks. Anyone else having issues with these 2 codes?
 
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Lupron Prolia

Is there a particular payer giving you issues or is this across the board. If it is across the board check the diagnosis code make sure it is 185 (if it applies). This is not typical.
 
I have found, many carriers require a P/A on those drugs. Also, in Ohio there is an LCD on documentation requirements for J0897.
 
How are you currently biiling for the Prolia injections. One of our Rhematology pratices ran into that same issues because they were billing the units incorrectly. Check your Local MAC for a LCD.

We were told to report the units of service as "60" due to the dose of the medication being 60mg. Have you been receiving denails?
 
Can anyone tell me what fee schedule you bill for these codes? one, 7.5mg for $750.00? Is this correct? Also, do you get preauths on this drug? I will check for the LCD...thx everyone.

Actually, I pulled the contract for the payer and saw it was in our contract to be paid at a lower price point and they are correcting the claim.

Thanks everyone.
 
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