Oncology & Hematology Coding Alert

Check your LCDs for information on J9217 reimbursement.

Has your practice checked that it's being adequately reimbursed for Lupron Depot? CMS determined it will no longer enforce least costly alternative (LCA) policies, which could be good news for you. Make sure you have all the details to ensure your practice gets the money you deserve.

Expect Full Pay as of April 19, 2010

In February, CMS lost a lawsuit regarding its LCA policy. Not long after, Medicare sent contractors an instruction that they must pay for Part B drugs according to the particular drug the patient actually received, not the price of the lowest cost alternative drug for which they were paying in the past.

History: The U.S. Court of Appeals for the D.C. Circuit sided with a Medicare beneficiary in the case of Hays v. Sebelius, which involved Medicare denying a patient a prescribed treatment for her lung disease. Medicare decided to pay for the LCA, going against her physician's advice. By ruling in favor of the plaintiff, the court overruled Medicare's decision.

You can read the entire legal case document on the American Urological Association (AUA) website at www.auanet.org/content/legislative-and-regulatory/washington-news/alerts/lca-09.pdf.

Timeline: All Medicare contractors were to be in compliance with this decision as of April 19, 2010, regarding the luteinizing hormone-releasing hormone (LHRH) analogs.

For example, Cahaba posted on their website "that they would no longer apply the LCA policy as of April 19, 2010, in accordance with CMS ruling," says Robin Shaw, billing manager for a Savannah, Ga., center.

Don't Alter Your Coding

Old method: In the past, most Medicare carriers adjusted your payment for drug codes down to the drug within the same classification with the lowest Average Sales Price (ASP), also known as applying the LCA. When there were two available drugs considered to have equivalent medical efficacy, Medicare  would only reimburse for the least expensive drug, regardless of the actual drug your physician used, explains Chandra L. Hines, business office manager for a Raleigh, N.C., practice. For example, Trelstar became the LCA for LHRH drugs in January 2007. So regardless of whether your physician used Lupron Depot (J9217, Leuprolide acetate [for depot suspension], 7.5 mg), Zoladex (J9202, Goserelin acetate implant, per 3.6 mg), or Trelstar (J3315, Injection, triptorelin pamoate, 3.75 mg), Medicare reimbursed you at the lower reimbursement rate for Trelstar.

Current method: Now, when you report J9217 for a Lupron Depot injection, your Medicare contractor should pay you for Lupron Depot, not the LCA (Trelstar), Hines says.

The benefit: The reimbursement for J9217 is significantly higher per unit than what had been deemed the LCA drug (J3315), Shaw says. Practices with a large number of prostate cancer patients should have seen a positive impact on revenue, she adds.

Monitor Carrier Updates, Confirm With EOBs

You need to be diligent and review your explanation of benefits and payment statements to ensure your contractor isn't still using the LCA payment policy.

Best bet: "Basically practices need to first go to their carrier's website to see if they have anything posted about the ruling," Shaw says.

For example, in WPS Medicare's local coverage determination (LCD) for "Luteinizing Hormone-Releasing Hormone (LHRH) Analogs" (L30479), you'll see this note under the revision history: "Criteria for least costly alternatives removed per directives from CMS" (www.wpsmedicare.com/part_b/policy/active/local/_files/l30479_inj039.pdf).

The directive was that "contractors shall not implement the LCA policy for any Part B drugs in new Local Coverage Determinations (LCDs). Contractors shall suspend and remove all LCA provisions  in current LCDs and adjudicate claims without using LCA for all  Part B drugs. Contractors shall no longer apply Chapter 15, Section 110.1.C.3 of the Benefit Policy Manual and Chapter 13, Sections 13.4(A) and the last sentence of 13.7.1 of the Program Integrity Manual in establishing LCDs for Part B drugs," the LCD states.

Next: "Practices need to be sure they are looking at their Medicare explanations of benefit to ensure they are getting proper reimbursement for the drug they gave," says Shaw.

(See the chart below for the LHRH analog therapy drugs that have been subject to LCA reductions in the past. Watch your claims for proper payment on these drugs under the new instruction.)

Code                                     Drug                                                                                     Name                              Units

J3315                                 Triptorelin pamoate                                                                    Trelstar                              3.75 mg

J9202                                 Goserelin acetate implant                                                           Zoladex                             3.6 mg

J9217                                Leuprolide acetate suspension                                                     Lupron Depot/Eligard          7.5 mg

J9225                               Histrelin implant                                                                           Vantas                               50 mg