Prolia (denosumab) is the brand name of denosumab medication prescribed to treat osteoporosis, an incurable bone disorder characterized by weak and more fragile bones that become vulnerable to fracture. Prolia is recommended for postmenopausal women as well as male patients at higher risk of fracture. Denosumab can effectively slow bone degradation while increasing density and strength thereby decreasing fracture risks while strengthening bones with regular skin injections once every six months in either upper arms, thighs or abdomen areas ideally. The CPT Code for Prolia Injection is J0897.
Prolia’s FDA–approved dosage is 60 mg (1 milliliter of 60 mg/mL solution in a prefilled syringe), to be taken once every six months and comes prefilled as an easy way of taking this dose. So that you may reap maximum benefits while simultaneously decreasing the risks for adverse side effects, please strictly abide by your doctor’s directions when taking Prolia to ensure maximum efficacy and minimize adverse reactions. For optimal effectiveness and to limit side effects.
Billing Guidelines for CPT Code for Prolia Injection J0897
Follow these steps when filing Prolia claims in order to prevent claims from being denied and increase the chances of approval.
| CPT Code | Description |
Billing Details |
| J0897 | Prolia (denosumab) injection | Bill 60 units of J0897, as each unit represents 1 mg. For a 60 mg dose, bill 60 units. |
| 96372 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular | Prolia is administered in a 60 mg/mL single-dose prefilled syringe. |
Documentation Requirements
- Write down the exact dosage that was administered by your physician.
- Take careful note of any amount discarded as well as what amount a vial was labeled with, then utilize JW modifiers to indicate them on separate claim lines.
Clinical Documentation for Monoclonal Antibody Therapy
Prolia (denosumab) is an IgG2 monoclonal antibody from humans that targets receptor activators of nuclear factor kappa B ligand. To be approved as monoclonal therapy documentation must include the following items.
- It is essential that clear criteria be identified when diagnosing osteoporosis.
- Record both the progression of disease as well as ongoing risks.
- Provide details regarding any contraindications, treatment failures, or adverse side effects associated with self- or oral osteoporosis medications used as part of subcutaneous injection therapy.
Additional Requirements for All Patients:
- Check your patient’s dental/oral health concerns have been examined.
- Patients should be advised to consume at least 1,000 mg of calcium daily as well as at least 400 IU of vitamin D daily.
Frequently Asked Questions (FAQ):
What is CPT code 96401 for Prolia?
CPT Code 96401 can be used to administer non-chemotherapeutic medications or substances through intramuscular or subcutaneous injection. Prolia, used to treat osteoporosis, is frequently given through this route, but always consult with both the physician and payer regarding its appropriateness, as the exact method may change based on the clinical situation and individual use may vary between payers or doctors.
What is procedure code J0897?
CPT Code J0897 is an HCPCS (Healthcare Common Procedure Coding System) code representing Denosumab (the generic form of Prolia). This billable HCPCS code represents Denosumab 1 mg.
Does insurance pay for Prolia injections?
Yes, all insurance plans, such as Medicare, typically provide Prolia injections that are deemed medically necessary when covered by their plan. As coverage varies depending on which policy one selects, and copayment and prior authorization conditions vary accordingly, it is wise to contact each provider individually in order to assess coverage details such as copayments and prior authorization conditions before purchasing Prolia (the typical price list is $1736.63 every six months; however, most patients don’t actually pay this price tag).
What is the CPT code J2506?
CPT code J2506 is used by healthcare providers when administering Pegfilgrastim outside of Prolia; this drug helps decrease chemotherapy patients’ chances of infection while increasing immunity levels. If using Prolia instead, an alternative HCPCS code such as J0897 would apply instead.
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