Resolved Bill Medicare for Prolia

[KateN_88735]

A patient will come in just for an injection with Prolia. The patient will bring his own medication. I dont know what injection code(s) to bill Medicare. Do i list the NDC#? Do i bill the E/M 99211 plus the injection code? or only injection code. pls. help. Thank you

 

[Laureen Jandroep]

1. Report the appropriate drug administration code for the injection.
2. Report the drug code (HCPCS code) for Prolia (denosumab), which is J0897.
3. Enter a nominal charge of $0.01 (one cent) for the drug itself

Source: https://www.cgsmedicare.com/partb/pubs/news/2021/03/cope20933.html

 

[Laureen Jandroep]

On the claim form, you need to provide the following information:

• In Item 19 of the CMS 1500 form (or Loop 2400 Segment SV101-7 for electronic claims), enter "Patient Purchased" or "No Cost Drug"
• In Item 24D (or Loop 2400 Segment SV101-2 for electronic claims), enter the drug HCPCS code (J0897 for Prolia)
• In Item 28 (or Loop 2300 CLM02 for electronic claims), enter $0.01 as the billed amount for the drug

 

[KateN_88735]

On the claim form, you need to provide the following information:

• In Item 19 of the CMS 1500 form (or Loop 2400 Segment SV101-7 for electronic claims), enter "Patient Purchased" or "No Cost Drug"
• In Item 24D (or Loop 2400 Segment SV101-2 for electronic claims), enter the drug HCPCS code (J0897 for Prolia)
• In Item 28 (or Loop 2300 CLM02 for electronic claims), enter $0.01 as the billed amount for the drug

Thank you very much Laureen.

 

[JenniferA_90235]

A patient will come in just for an injection with Prolia. The patient will bring his own medication. I dont know what injection code(s) to bill Medicare. Do i list the NDC#? Do i bill the E/M 99211 plus the injection code? or only injection code. pls. help. Thank you

96372 or 96401 and J0897 with a no charge modifier (to show it was given but the patient brought it in)

 

[Raymond_62028]

You don't need to list the NDC# unless it's specifically required by your practice or insurance. If you’re doing a simple injection and there’s no significant evaluation or management, you don’t need to bill the E/M code (99211). Just the injection code should be enough.