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How to get paid for Prolia injection?


Earlier Prolia injection was billed using HCPCS code either J3490 (Unclassified drugs) or J3590 (Unclassified biologics) but
effective from January 1, 2012, a new HCPCS procedure code has been assigned to the drug denosumab (Prolia or Xgeva).

J0897 Injection, denosumab, 1 mg

The drug denosumab has two brand names with two different indications. The brand names and their indications are:

Prolia
Denosumab injection (Prolia) is used to treat osteoporosis (a condition in which the bones become thin and weak and break easily) in women who have undergone menopause and have an increased risk for fractures (broken bones) or who cannot take or did not respond to other medications for osteoporosis.

Xgeva
Denosumab injection (Xgeva) is used to reduce fractures from cancer that began in another part of the body but has spread to the bones. Denosumab injection (Xgeva) is not used to reduce fractures from multiple myeloma (cancer that begins in the plasma cells [a type of white blood cell that produces substances needed to fight infection]).

When billing the drug denosumab (Prolia) for patients with postmenopausal osteoporosis, the following ICD-9-CM code must be present on the claim:

733.01 - Senile osteoporosis

When billing the drug denosumab (Xgeva ) for patients with bone metastases from solid tumors, the following ICD-9-CM code must be present on the claim:

198.5 - Secondary malignant neoplasm of bone and bone marrow

Please also indicate in the comment section of the claim which drug is being administered, Prolia or Xgeva.

Please Note: When denosumab (Prolia or Xgeva ) is reported for Medicare payment using the recommend diagnosis code above, the medical record must clearly demonstrate the patient has, in fact, been so diagnosed. Utilizing the recommended diagnosis code in situations where medical records do not support the reported diagnosis is not appropriate.

Please also see the list of new J codes effective from Jan 1, 2012

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