Wiki Prolia injections

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We do all the time - but the j code should be J0897 60 units
Reimbursement for the J0897 varies from 823-879, the 96372 is approximately $25 on average
 
We bill the admin code of 96401 with J0897, because Prolia is a biologic---and the 96401 is the appropriate code for that category of drug. That also means that your reimbursement would be greater for the admin because of the risks/side effects for biologics. I would think you would base your charged amount on the cost of the drug to your clinic---possibly increase by 25%?
 
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I agree with this new member's post. We use 96401 for the admin as well. However, there may be certain carriers that want you to use the 96372. I may be wrong, but Aetna may be one of the carriers that want the 96372 used, but I'd make sure by checking it out first.
 
Item Coding Information (HCPCS1/CPT?2/ICD-9-CM3) Notes
Prolia? J0897, injection, denosumab, 1 mg Permanent J-code effective for dates of service on
or after 01/01/2012
Prolia? is supplied as a 60 mg dose;
its NDC is 55513-0710-01
Administration 96372, therapeutic, prophylactic, or diagnostic
injection (specify substance or drug), subcutaneous
or intramuscular;
OR 96401, chemotherapy administration,
subcutaneous or intramuscular, non-hormonal
antineoplastic
The Medicare Claims Processing Manual (CPM) and the American
Medical Association (AMA) indicate that chemotherapy codes
may be appropriate in the treatment of noncancer diagnosis or
to substances such as certain monoclonal antibody agents, and
other biologic response modi5ers. However, third-party payors (or
local carriers in the case of Medicare) make the determination for
which speci5c codes are appropriate for billing
Healthcare provider should consult the payor or Medicare
contractor to determine which code is most appropriate for
administration of Prolia?
 
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