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Explore This IssueAugust 2019
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CPT: 96372 & J0897x60
The administration code for this service is 96372 therapeutic/diagnostic subcutaneous/intramuscular. Although the drug is a monoclonal antibody, it does not meet the work to be billed under the higher chemotherapy code 96401 (chemotherapy; injection subcutaneous/intramuscular). Also, the nursing CPT code 99211 should not be billed, because the service is built into the relative value unit (RVU) for the fee schedule.
The ICD-10 code is age-related osteoporosis without a current pathological fracture.
This claim was denied by Medicare, and records were requested, not only for this claim but for an additional 20 denosumab claims. The following documentation was requested:
- Beneficiary name and date of service on all documentation;
- Signed physician/provider order for the drug;
- Documentation to support the medical necessity for the administration of the injection;
- Stage of treatment for accurate dose administration calculation of the drug (i.e., first dose or subsequent dosing);
- Documentation of the administration of the medication, including the patient’s name, date, dosage, time, route, site of the injection and the signature of the individual who administered the drug; and
- Documentation legible and complete (including signature[s]).
This claim was denied for not meeting medical necessity, because denosumab can only be administered every six months. To be a covered service, this injection should have been delayed until six months after the previous dose was actually given—not when it was originally scheduled (i.e., on Aug. 5, 2019).
The dosing regimen for denosumab is once every six months, and this dosing guideline is strictly followed by Medicare to meet medical necessity. If a dose is missed, the injection should be administered as soon as possible and the following injection scheduled six months from the date of the last injection and every six months thereafter.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at firstname.lastname@example.org or call 404-633-3777 x820.
9/22/2020 Note: The ACR publishes Coding Corner to address questions from members and their staff on procedural and diagnosis coding. However, the department is informational only and provides coding instructions based on current coding conventions and guidelines from the CPT. The ACR coding staff does not provide clinical criteria for establishing diagnoses or procedural services and has no authority to offer clinical definitions or guidance. Coding Corner articles are not intended to be used as criteria for payer policies, and members are encouraged to verify coverage and benefits for all office visits and procedures. View the ACR Position Statements for additional information on such areas as complexity of biologics, prior authorization, access to care, etc.