HCPCS Code J0897

Official Description

Injection, denosumab, 1 mg

Short Descr	Denosumab injection
Related Drugs	Prolia
Coverage	Carrier Priced
Pricing Indicator(s)	51 – Drugs
MPI	A – Not applicable, as HCPCS priced under one methodology
ASC Payment Group Code	YY – 1/01/2012
BETOS	O1E – Other drugs
TOS Code(s)	1 – Medical care
Added Date	1/1/2012
Status Code	Excluded from Physician Fee Schedule by Regulation
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	9 - Not Applicable
Multiple Procedures (51)	9 - Concept does not apply.
Bilateral Surgery (50)	9 - Concept does not apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	9 - Concept does not apply.
Co-Surgeons (62)	9 - Concept does not apply.
Team Surgery (66)	9 - Concept does not apply.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Nonpass-Through Drugs and Nonimplantable Biologicals, Including Therapeutic Radiopharmaceuticals
ASC Payment Indicator	Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate.
MUE	120
MUE	0
OTS Orthotic	No
CCS Clinical Classification	240 - Medications (Injections, infusions and other forms)

JZ	Zero drug amount discarded/not administered to any patient
JB	Administered subcutaneously
GA	Waiver of liability statement issued as required by payer policy, individual case
EJ	Subsequent claims for a defined course of therapy, e.g., epo, sodium hyaluronate, infliximab
X2	Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services
Q1	Routine clinical service provided in a clinical research study that is in an approved clinical research study
JW	Drug amount discarded/not administered to any patient
GW	Service not related to the hospice patient's terminal condition
JA	Administered intravenously
59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
CR	Catastrophe/disaster related
JG	Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes
Q6	Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
GY	Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
LT	Left side (used to identify procedures performed on the left side of the body)
TB	Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes
GC	This service has been performed in part by a resident under the direction of a teaching physician
GZ	Item or service expected to be denied as not reasonable and necessary
UD	Medicaid level of care 13, as defined by each state
AQ	Physician providing a service in an unlisted health professional shortage area (hpsa)
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
RT	Right side (used to identify procedures performed on the right side of the body)
25	Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59.
GF	Non-physician (e.g. nurse practitioner (np), certified registered nurse anesthetist (crna), certified registered nurse (crn), clinical nurse specialist (cns), physician assistant (pa)) services in a critical access hospital
KX	Requirements specified in the medical policy have been met
Q5	Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
X1	Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
26	Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
32	Mandated services: services related to mandated consultation and/or related services (eg, third party payer, governmental, legislative or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.
57	Decision for surgery: an evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of e/m service.
79	Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
95	Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
97	Rehabilitative services: when a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified health care professional may add modifier 97 to the service or procedure code to indicate that the service or procedure provided was a rehabilitative service. rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled.
AG	Primary physician
AO	Alternate payment method declined by provider of service
CG	Policy criteria applied
EY	No physician or other licensed health care provider order for this item or service
FB	Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples)
FP	Service provided as part of family planning program
FQ	The service was furnished using audio-only communication technology
GE	This service has been performed by a resident without the presence of a teaching physician under the primary care exception
GX	Notice of liability issued, voluntary under payer policy
JE	Administered via dialysate
KO	Single drug unit dose formulation
KY	Dmepos item subject to dmepos competitive bidding program number 5
PD	Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
PN	Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
PO	Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
PT	Colorectal cancer screening test; converted to diagnostic test or other procedure
Q0	Investigational clinical service provided in a clinical research study that is in an approved clinical research study
SA	Nurse practitioner rendering service in collaboration with a physician
SB	Nurse midwife
SL	State supplied vaccine
SS	Home infusion services provided in the infusion suite of the iv therapy provider
XE	Separate encounter, a service that is distinct because it occurred during a separate encounter
XP	Separate practitioner, a service that is distinct because it was performed by a different practitioner
XS	Separate structure, a service that is distinct because it was performed on a separate organ/structure