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Revised Billing Regulations for Prolia under Medicare Coverage

Prolia billing guidelines within Medicare framework

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Revised billing directives for administering Prolia under Medicare
Revised billing directives for administering Prolia under Medicare

Unfiltered Medicare Billing and Coding Guidelines for Prolia (Denosumab) Under Part B

Prolia (Denosumab) - The Breakdown

Revised Billing Regulations for Prolia under Medicare Coverage

Prolia, a subcutaneous injectable, is primarily used to treat postmenopausal osteoporosis and other bone-related disorders. Medicare Part B typically covers Prolia when it's administered in a medical setting.

The HCPCS Code for Prolia (Denosumab)

  • The HCPCS code for Prolia is J1094 (Injection, denosumab, 1 mg).

Billing Basics

  1. Service Environment: Prolia gets covered under Medicare Part B when administered in an office or outpatient facility setting. Submit claims to the Medicare Part B claims processor (MAC).
  2. Dosage and Administration: In most cases, Prolia is given as a 60 mg injection once every six months. Be sure to specify the dose in your claims.
  3. Coding and Billing Flexibility:
  4. J1094: Primary code utilised for Prolia; use it for every milligram administered.
  5. Modifier Usage: Depending on the service setting or billing practitioner, modifiers may be necessary to explain the service or provider type. Common modifiers can detail service place or provider type, but always verify specific modifiers based on Medicare guidelines.
  6. Reimbursement Scenario:
  7. Reimbursement for Prolia is usually based on the Average Sales Price (ASP) plus a negotiated percentage. This changes quarterly and can be found on the Medicare Part B ASP Pricing Files through the CMS website.
  8. Coding and Billing Variants:
  9. Modifier 26: This modifier might be used to indicate the professional service component (e.g., a physician or nurse administering the injection).
  10. Modifier 25: This modifier could be used to show an additional evaluation and management service on the same day as the injection.
  11. Part B vs. Part D: Ensure that Prolia is billed under Part B if administered in an outpatient setting. Self-administration of Prolia can fall under Part D coverage.

Compliance and Documentation

  1. Record Keeping: Maintain detailed records of the administration date, dosage, and reason for treatment.
  2. Medicare Regulation Compliance: Ensure strict adherence to Medicare's billing guidelines and any changes made to the ASP Pricing Files.

Additional Resources

  1. CMS ASP Pricing Files: Find the latest pricing information on the CMS website.
  2. Medicare Claims Processing Manual: Chapter 17 provides in-depth guidance on billing for drugs and biologicals.

Remember: Continuously refer to the most current Medicare guidelines and resources for updates or changes in billing and coding procedures.

  1. The HCPCS code for Prolia, a medication often used to treat postmenopausal osteoporosis, is J1094 (Injection, denosumab, 1 mg), and it is covered under Medicare Part B when administered in an office or outpatient facility setting.
  2. When submitting claims for Prolia to the Medicare Part B claims processor (MAC), it is essential to provide the service environment and specify the dose administered, as well as the reasons for treatment, to ensure compliance with Medicare guidelines.
  3. In some cases, modifiers such as Modifier 26 (to indicate the professional service component) or Modifier 25 (to show an additional evaluation and management service on the same day as the injection) may be necessary to add clarity to the billing process, as per Medicare requirements.

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