Wiki Prolia injection

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bonzaibex

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Are any physician practices billing Medicare and getting paid for Prolia injections (aka denosumab)? If so, how much is Medicare allowing for your area?

Becky, CPC
 
I am billing it (Ohio) and they are paying. Bill out: J3490 w NDC #55513071001. They are allowing $825 & paying the 80% $660. Almost all our payers are paying & if they don't Prolia Plus will fight it.
 
prolia

our PCP offices were billing the prolia under J3490 and 96372, a few months ago they were told by the Prolia rep to change to J3590 and 96401. FL medicare pays the same for the J code, but doubles the reimbursement for the 96401. I wanted to know if this is OK. The HCPCS books still says Prolia should be J3490. Does anybody have an answer to this question. Should I tell my offices to go back to the J3490 and 96372?:confused:
 
Billing Specialist

We have been billing Medicare here in Florida for the Prolia injection and get nothing but denials. I have even sent the information necessary for payment and they still deny, anyone have any suggestions on what the issue could be? We use J3490 with 96372. In box 19 we put Denosumab 60mg sc inj then the NDC code. We can't seem to get it paid. Any suggestions?:
 
Prolia

In my Coders' Desk Reference for Procedures book the defination for code range 96401-96402 is as follows..
The physician or supervised assistant prepares and administers non-hormonal medication to combat diseases such as malignant neoplasms or microorganisms. These codes apply to medication injected under the skin (subcutaneous) or into a muscle (intramuscular) often in the arm or leg. Report 96402 for a hormanal medication administered to combat diseases such as malignant neoplasms or microorganisms.
 
donna.lowery2010@gmail.com said:
We have been billing Medicare here in Florida for the Prolia injection and get nothing but denials. I have even sent the information necessary for payment and they still deny, anyone have any suggestions on what the issue could be? We use J3490 with 96372. In box 19 we put Denosumab 60mg sc inj then the NDC code. We can't seem to get it paid. Any suggestions?:
Click to expand...

We bill Medicare here in Virginia for Prolia and are receiving reimbursement. What ICD-9 code are you using? Perhaps that could be the issue. We use the same J-code and admin code you have listed above and put the info in box 19 as you have stated also. We use ICD-9 733.01 as this is the diagnosis documented in the chart that warrants the Prolia.

I hope this info helps!
 
Prolia has been such a pain for us as well, but I do have to say that our Prolia rep is great and has helped us get reimbursed every step of the way. If we haven't gotten reimbursed by the insurance company, Prolia has stepped in to help fight the fight and/or the patient has qualified for the assistance program. We are in Florida and were actually told by our rep to bill J3590 and 96401. They stated we could bill the 96401 as Prolia was a biological drug and was covered under this code.
 
need criteria

Can anyone tell me where to get the criteria for this injection for medicare and reg ins they can only have this every 6 months correct? is that for medicare and reg ins?
 
Screening lab for prolia

I was told that first you must do thyroid testing before starting Prolia? Does anyone know if this is correct and what DX code would cover the screening lab work?
 
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