SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Denosumab (Prolia ™, Xgeva ™)

A52399

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Contractor Information

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General Information

Source Article ID
N/A
Article ID
A52399
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Denosumab (Prolia ™, Xgeva ™)
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2023
Revision Ending Date
09/30/2023
Retirement Date
N/A
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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

N/A

Article Guidance

Article Text

This article contains billing and coding guidelines that complement the Local Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and Off-Label Uses.

Abstract:

Denosumab is a receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor. Binding to the transmembrane or soluble protein RANKL inhibits the formation, function, and survival of osteoclasts resulting in decreased bone resorption and increased bone mass and strength.

Supplemental calcium and vitamin D are required.

Hypocalcemia must be corrected prior to initiation of denosumab therapy.

The FDA has approved the use of denosumab (Prolia™). Medicare has determined under Section 1861(t) that this drug may be paid when it is administered incident to a physician’s service and is determined to be reasonable and necessary. Such determination of reasonable and necessary is currently left to the discretion of the Medicare contractors.

Documentation Requirements:

The patient's medical record should contain documentation that fully supports the medical necessity for the administration of either formulation. Requirements specific to each formulation are as follows:

Denosumab(Prolia®)

Patient adequately supplemented with calcium and vitamin D (calcium 1000 mg daily and at least 400 IU vitamin D daily).

For postmenopausal osteoporosis at high risk for fracture, documentation should include but is not limited to:

  1. Menopausal status (for female beneficiaries only)
  2. Patients age and sex.
  3. Documentation supporting the diagnosis of osteoporosis.
  4. Previous treatment of osteoporosis, agents used, outcomes and adverse reactions if any.
  5. History of previous fractures, including type of fracture, cause and time since occurrence.
  6. Risk factors for future fracture including preventive measures.

For the treatment of cancer treatment-induced bone loss (CTIBL) due to hormone ablation such documentation should include, but is not limited to:

  1. Documentation supporting the diagnosis of breast cancer or nonmetastatic prostate cancer.
  2. Use of adjuvant aromatase inhibitor (AI) therapy or androgen deprivation therapy (ADT).
  3. Additional diagnosed risk factors, if any.

Denosumab (Xgeva®)

Documentation should include, but is not limited to:

For treatment of bone metastasis from a solid tumor:

  1. Patient adequately supplemented with calcium and vitamin D 

For management of hypercalcemia of malignancy (ICD-10-CM code E83.52)

  1. The related malignancy
  2. The rationale for the use of the drug

 Utilization:

Dose and frequency should be in accordance with the FDA label or recognized compendia (for off-label uses). When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Coding Information:

  1. HCPCS code J0897 should be used to report denosumab (Prolia™, Xgeva™) for claims submitted to the Part A and Part B MAC.
  2. The administration of denosumab, when billed, should be billed using the therapeutic administration code 96372 (Therapeutic prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.
  3. Correct coding requires that a bone metastasis diagnosis (ICD-10-CM code C79.51) be present on the claim as the primary diagnosis and the original cancer or history of cancer be included as the secondary diagnosis. This article does not limit the primary cancer (as long as it is a solid tumor and not a myeloma or other cancer of the blood). Effective for dates of service on or after 01/04/2018, the FDA has approved denosumab (Xgeva®) for the treatment of skeletal-related events in patients with multiple myeloma.
  4. Any significant and separately identifiable E&M service billed should accurately reflect the level of the components documented. Observation of the patient by the physician post-injection may be included in the E&M service. Only face-to-face time with the physician may be considered. Observation and treatment time by the office or hospital staff may not be billed separately or counted towards a physician E&M service.


FDA and Compendia Review

Clinical Pharmacology Web site. http://www.clinicalpharmacology.com/. Accessed 12/07/2022.

FDA label for Prolia® https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/125320s202lbl.pdf

FDA label for XGEVA® https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/125320s196s199lbl.pdf

Lexi-Drugs Web site. http://online.lexi.com. Accessed 12/07/2022.

Micromedex DrugDex®. http://www.thomsonhc.com/home/dispatch. Accessed 12/07/2022.

National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp. Accessed 12/07/2022.

Prolia Web site. http://www.proliahcp.com/. Accessed 10/01/2010.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
96372 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR
J0897 INJECTION, DENOSUMAB, 1 MG
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(206 Codes)
Group 1 Paragraph

For the treatment of patients with bone metastases from solid tumors. Note: multiple myeloma, lymphoma and other cancers of the blood are not considered solid tumors). Effective for dates of service on or after 01/04/2018, the FDA has approved denosumab (Xgeva®) for the treatment of skeletal-related events in patients with multiple myeloma.

ICD-10-CM code E83.52 should be used to report management of hypercalcemia of malignancy.

Group 1 Codes
Code Description
C79.51 Secondary malignant neoplasm of bone
C90.00 Multiple myeloma not having achieved remission
C90.01 Multiple myeloma in remission
C90.02 Multiple myeloma in relapse
C90.10 Plasma cell leukemia not having achieved remission
C90.11 Plasma cell leukemia in remission
C90.12 Plasma cell leukemia in relapse
C90.20 Extramedullary plasmacytoma not having achieved remission
C90.21 Extramedullary plasmacytoma in remission
C90.22 Extramedullary plasmacytoma in relapse
C90.30 Solitary plasmacytoma not having achieved remission
C90.31 Solitary plasmacytoma in remission
C90.32 Solitary plasmacytoma in relapse
E83.52 Hypercalcemia
M84.50XA - M84.58XS Pathological fracture in neoplastic disease, unspecified site, initial encounter for fracture - Pathological fracture in neoplastic disease, other specified site, sequela

Group 2

(290 Codes)
Group 2 Paragraph

Treatment of osteoporosis at high risk for fracture


Group 2 Codes
Code Description
M80.00XA - M80.88XS Age-related osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture - Other osteoporosis with current pathological fracture, vertebra(e), sequela
M80.8AXA Other osteoporosis with current pathological fracture, other site, initial encounter for fracture
M80.8AXD Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing
M80.8AXG Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing
M80.8AXK Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with nonunion
M80.8AXP Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with malunion
M80.8AXS Other osteoporosis with current pathological fracture, other site, sequela
M81.0 Age-related osteoporosis without current pathological fracture
M81.8 Other osteoporosis without current pathological fracture

Group 3

(289 Codes)
Group 3 Paragraph

For beneficiaries who have failed or are intolerant to other available osteoporosis therapy, at least one ICD-10-CM code from Group 3 and Group 4 must be billed.

Codes indicating a diagnosis of osteoporosis



Group 3 Codes
Code Description
M80.00XA - M80.88XS Age-related osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture - Other osteoporosis with current pathological fracture, vertebra(e), sequela
M80.8AXA Other osteoporosis with current pathological fracture, other site, initial encounter for fracture
M80.8AXD Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing
M80.8AXG Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing
M80.8AXK Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with nonunion
M80.8AXP Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with malunion
M80.8AXS Other osteoporosis with current pathological fracture, other site, sequela
M81.0 Age-related osteoporosis without current pathological fracture

Group 4

(9 Codes)
Group 4 Paragraph

For Intolerance to other available osteoporosis therapy

Group 4 Codes
Code Description
N18.30 Chronic kidney disease, stage 3 unspecified
N18.31 Chronic kidney disease, stage 3a
N18.32 Chronic kidney disease, stage 3b
N18.4 Chronic kidney disease, stage 4 (severe)
N18.5 Chronic kidney disease, stage 5
T50.995S Adverse effect of other drugs, medicaments and biological substances, sequela
T88.7XXS Unspecified adverse effect of drug or medicament, sequela
Z88.8 Allergy status to other drugs, medicaments and biological substances
Z92.29 Personal history of other drug therapy

Group 5

(302 Codes)
Group 5 Paragraph

As a treatment to increase bone mass in men at high risk for fracture receiving androgen deprivation therapy for nonmetastatic prostate cancer. An ICD-10-CM code from Group 5, Group 6 and Group 7 must be reported.

Group 5 Codes
Code Description
M80.00XA - M80.88XS Age-related osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture - Other osteoporosis with current pathological fracture, vertebra(e), sequela
M80.8AXA Other osteoporosis with current pathological fracture, other site, initial encounter for fracture
M80.8AXD Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing
M80.8AXG Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing
M80.8AXK Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with nonunion
M80.8AXP Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with malunion
M80.8AXS Other osteoporosis with current pathological fracture, other site, sequela
M81.0 Age-related osteoporosis without current pathological fracture
M81.6 Localized osteoporosis [Lequesne]
M81.8 Other osteoporosis without current pathological fracture
M85.80 Other specified disorders of bone density and structure, unspecified site
M85.831 Other specified disorders of bone density and structure, right forearm
M85.832 Other specified disorders of bone density and structure, left forearm
M85.839 Other specified disorders of bone density and structure, unspecified forearm
M85.851 Other specified disorders of bone density and structure, right thigh
M85.852 Other specified disorders of bone density and structure, left thigh
M85.859 Other specified disorders of bone density and structure, unspecified thigh
M85.88 Other specified disorders of bone density and structure, other site
M85.89 Other specified disorders of bone density and structure, multiple sites
M85.9 Disorder of bone density and structure, unspecified
M89.9 Disorder of bone, unspecified

Group 6

(2 Codes)
Group 6 Paragraph

N/A

Group 6 Codes
Code Description
C61 Malignant neoplasm of prostate
Z85.46 Personal history of malignant neoplasm of prostate

Group 7

(4 Codes)
Group 7 Paragraph

N/A

Group 7 Codes
Code Description
Z48.816 Encounter for surgical aftercare following surgery on the genitourinary system
Z51.89 Encounter for other specified aftercare
Z79.818 Long term (current) use of other agents affecting estrogen receptors and estrogen levels
Z79.899 Other long term (current) drug therapy

Group 8

(302 Codes)
Group 8 Paragraph

As a treatment to increase bone mass in women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer. An ICD-10-CM code from Group 8, Group 9 and Group 10 must be reported.

Group 8 Codes
Code Description
M80.00XA - M80.88XS Age-related osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture - Other osteoporosis with current pathological fracture, vertebra(e), sequela
M80.8AXA Other osteoporosis with current pathological fracture, other site, initial encounter for fracture
M80.8AXD Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing
M80.8AXG Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing
M80.8AXK Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with nonunion
M80.8AXP Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with malunion
M80.8AXS Other osteoporosis with current pathological fracture, other site, sequela
M81.0 Age-related osteoporosis without current pathological fracture
M81.6 Localized osteoporosis [Lequesne]
M81.8 Other osteoporosis without current pathological fracture
M85.80 Other specified disorders of bone density and structure, unspecified site
M85.831 Other specified disorders of bone density and structure, right forearm
M85.832 Other specified disorders of bone density and structure, left forearm
M85.839 Other specified disorders of bone density and structure, unspecified forearm
M85.851 Other specified disorders of bone density and structure, right thigh
M85.852 Other specified disorders of bone density and structure, left thigh
M85.859 Other specified disorders of bone density and structure, unspecified thigh
M85.88 Other specified disorders of bone density and structure, other site
M85.89 Other specified disorders of bone density and structure, multiple sites
M85.9 Disorder of bone density and structure, unspecified
M89.9 Disorder of bone, unspecified

Group 9

(41 Codes)
Group 9 Paragraph

N/A

Group 9 Codes
Code Description
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.019 Malignant neoplasm of nipple and areola, unspecified female breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.119 Malignant neoplasm of central portion of unspecified female breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.219 Malignant neoplasm of upper-inner quadrant of unspecified female breast
C50.311 Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.319 Malignant neoplasm of lower-inner quadrant of unspecified female breast
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.419 Malignant neoplasm of upper-outer quadrant of unspecified female breast
C50.511 Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.619 Malignant neoplasm of axillary tail of unspecified female breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.819 Malignant neoplasm of overlapping sites of unspecified female breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
C50.919 Malignant neoplasm of unspecified site of unspecified female breast
D05.00 Lobular carcinoma in situ of unspecified breast
D05.01 Lobular carcinoma in situ of right breast
D05.02 Lobular carcinoma in situ of left breast
D05.10 Intraductal carcinoma in situ of unspecified breast
D05.11 Intraductal carcinoma in situ of right breast
D05.12 Intraductal carcinoma in situ of left breast
D05.80 Other specified type of carcinoma in situ of unspecified breast
D05.81 Other specified type of carcinoma in situ of right breast
D05.82 Other specified type of carcinoma in situ of left breast
D05.90 Unspecified type of carcinoma in situ of unspecified breast
D05.91 Unspecified type of carcinoma in situ of right breast
D05.92 Unspecified type of carcinoma in situ of left breast
Z85.3 Personal history of malignant neoplasm of breast
Z86.000 Personal history of in-situ neoplasm of breast

Group 10

(4 Codes)
Group 10 Paragraph

N/A

Group 10 Codes
Code Description
Z51.89 Encounter for other specified aftercare
Z79.811 Long term (current) use of aromatase inhibitors
Z79.818 Long term (current) use of other agents affecting estrogen receptors and estrogen levels
Z79.899 Other long term (current) drug therapy

Group 11

(20 Codes)
Group 11 Paragraph

For the treatment of adults and skeletally mature adolescents with giant cell tumor of bone that is unresectable or where surgical resection is likely to result in severe morbidity.

Group 11 Codes
Code Description
C40.00 Malignant neoplasm of scapula and long bones of unspecified upper limb
C40.01 Malignant neoplasm of scapula and long bones of right upper limb
C40.02 Malignant neoplasm of scapula and long bones of left upper limb
C40.10 Malignant neoplasm of short bones of unspecified upper limb
C40.11 Malignant neoplasm of short bones of right upper limb
C40.12 Malignant neoplasm of short bones of left upper limb
C40.20 Malignant neoplasm of long bones of unspecified lower limb
C40.21 Malignant neoplasm of long bones of right lower limb
C40.22 Malignant neoplasm of long bones of left lower limb
C40.30 Malignant neoplasm of short bones of unspecified lower limb
C40.31 Malignant neoplasm of short bones of right lower limb
C40.32 Malignant neoplasm of short bones of left lower limb
C40.80 Malignant neoplasm of overlapping sites of bone and articular cartilage of unspecified limb
C40.81 Malignant neoplasm of overlapping sites of bone and articular cartilage of right limb
C40.82 Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb
C40.90 Malignant neoplasm of unspecified bones and articular cartilage of unspecified limb
C40.91 Malignant neoplasm of unspecified bones and articular cartilage of right limb
C40.92 Malignant neoplasm of unspecified bones and articular cartilage of left limb
C41.9 Malignant neoplasm of bone and articular cartilage, unspecified
D48.0 Neoplasm of uncertain behavior of bone and articular cartilage
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
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Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2023 R14

Based on compendia review, ICD-10 codes C90.10, C90.11, C90.12, C90.20, C90.21, C90.22, C90.30, C90.31 and C90.32 have been added to the Group 1 ICD-10 code list. Based on provider comment, ICD-10 code Z79.818 has been added to ICD-10 code lists for Groups 7 and 10.

04/21/2022 R13

The article has been corrected to remove the following statement: (calcium 1000 mg daily and at least 400 IU vitamin D daily) from the “Documentation Requirements” for Denosumab (Xgeva®).

04/21/2022 R12

The following statement has been further clarified to add (calcium 1000 mg daily and at least 400 IU vitamin D daily).

Patient adequately supplemented with calcium and vitamin D (calcium 1000 mg daily and at least 400 IU vitamin D daily).

07/08/2021 R11

The following clarification has been added to the Documentation Requirements for Denosumab (Prolia®) and (Xgeva®): Patient adequately supplemented with calcium and vitamin D.

10/01/2020 R10

Based on the annual ICD-10 code update, the following ICD-10 codes (M80.0AXA, M80.0AXD, M80.0AXG, M80.0AXK, M80.0AXP and M80.0AXS) have been added to ICD-10 code range M80.00XA - M80.88XS in Groups 2, 3, 5 and 8. The following ICD-10 codes (M80.8AXA, M80.8AXD, M80.8AXG, M80.8AXK, M80.8AXP and M80.8AXS) have been added to Groups 2, 3, 5 and 8. In Group 4, ICD-10 code N18.3 has been deleted and replaced with N18.30, N18.31 and N18.32. The descriptor for ICD-10 code Z88.8 was changed in Group 4.

11/07/2019 R9

This article was converted to the new Billing and Coding Article format. The Article Text section has been revised to remove the indications and limitations which can be found on the FDA Web site and in the approved compendia. The “Sources of Information” has been revised to “FDA and Compendia Review.” Sources of information other than the FDA and compendia have been moved to a PDF file attached to LCD L33394. The Bill type codes have been removed from this article. Guidance on these codes is available in the Bill type code section.

05/18/2018 R8

The following indication has been added for denosumab (Prolia®):

    Glucocorticoid-induced osteoporosis in men and women at high risk of fracture who are either initiating or continuing systemic glucocorticoids in a daily dosage equivalent to 7.5 mg or greater of prednisone and expected to remain on glucocorticoids for at least 6 months (Effective May 18, 2018 based on FDA approval).
01/04/2018 R7

The indications for Xgeva® have been revised to add:

    Treatment of skeletal-related events in patients with multiple myeloma (Effective January 4, 2018 based on FDA approval).

The limitation for Xgeva® has been revised to add: 

    Effective for dates of service on or after 01/04/2018, the FDA has approved denosumab (Xgeva®) for the treatment of skeletal-related events in patients with multiple myeloma.

Coding guideline #3 and the first paragraph in the Group 1 paragraph section for “Covered ICD-10 Codes” have been revised to add:

    Effective for dates of service on or after 01/04/2018, the FDA has approved denosumab (Xgeva®) for the treatment of skeletal-related events in patients with multiple myeloma.

ICD-10-CM codes C90.00, C90.01 and C90.02 have been added to Group 1 for “Covered ICD-10 Codes” effective for dates of service on or after 01/04/2018.

The first paragraph in the "Indications" section of the article has been revised to include Lexi-Drug compendium. The Lexi-Drug Web site has been added to the “Sources of Information” section of the article.

03/23/2017 R6 ICD-10-CM codes D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.90, D05.91, D05.92 and Z86.000 have been added to the Group 9 list of ICD-10-CM codes as a treatment to increase bone mass in women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer effective for dates of service on or after 10/01/2015. The language in "Coding Information" guideline #2 has been changed from "if billed" to "when billed."
02/01/2017 R5 ICD-10-CM code M81.8 has been added to the Group 2 list of codes in the “Covered ICD-10 Codes” section of the article effective 10/01/2015. Coding guideline #2 in the “Coding Information” section of the article has been revised to change the administration code from 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic) to 96372 (Therapeutic prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular effective for dates of service on or after 03/17/2017. CPT code 96401 has been removed from the "CPT/HCPCS Codes" section and CPT code 96372 has been added.
10/01/2015 R4 ICD-10-CM code Z48.816 has been added to the Group 7: list of codes in the “Covered ICD-10 Codes” section of the article effective 10/01/2015.
10/01/2015 R3 ICD-10 CM codes M85.80, M85.831, M85.832, M85.839, M85.851, M85.852, M85.859, M85.88 and M85.89 have been added to the Group 5: and Group 8: lists of codes in the “Covered ICD-10 Codes” section of the article effective 10/01/2015.
10/01/2015 R2 The place of service guidelines for the Part B MAC have been removed. ICD-10-CM code C79.52 has been removed from the Group 1: Codes in the "Covered ICD-10 Codes" section and ICD-10-CM codes M84.50XA-M84.58XS have been added. ICD-10-CM codes M80.00XA-M80.88XS have been added to the following Group Code lists: Group 2:, Group 3:, Group 5: and Group 8:. The ICD-10-CM codes for intolerance to other available osteoporosis therapy have been moved to Group 4. ICD-10-CM code T88.7XXS has been added to the Group 4: Codes. ICD-10-CM code M94.9 has been removed from the Group 5: and Group 8: lists of codes. ICD-10-CM codes C50.019, C50.119, C50.219, C50.319, C50.419, C50.519, C50.619, C50.819 and C50.919 have been added to the Group 9: Codes. ICD-10-CM codes C40.00, C40.10, C403.20, C40.30, C40.80 and C40.90 have been added to the Group 11: Codes.
10/01/2015 R1 Updated to include revisions made since April 2014. ICD-10-CM code E83.52 has been added to the Group 1: Codes in the Covered ICD-10 Codes section.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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