Urology Coding Alert

The story Medicare Reimburses for Zoladex, Not Lupron on page 28 of the April 2000 issue of Urology Coding Alert was misleading because the headline and the initial paragraph said Medicare does not pay for Lupron. Medicare does pay for it, as the article stated, but its allowable for Lupron is less in proportion to the actual cost of the drug, than for Zoladex. Medicare will pay for 80 percent of the allowed amount for Lupron, as well as for Zoladex. Lupron actually costs more than the allowed amount.

The following are the Medicare-allowed amounts for Lupron and Zoladex, according to Ruth Borrero, assistant billing manager for Urology Associates, an eight-provider practice in Manhasset, N.Y.

For one month of Lupron: a 7.5-milligram dose is coded J9217. The Medicare-allowed amount is $564.91. Of this, Medicare pays $451.93, and the patient co-pay, which is 20 percent, is $112.98.

For one month of Zoladex: a 3.6-milligram dose is coded J9202. The Medicare allowed amount is $446.49. Of this, Medicare pays $357.19, and the patient co-pay, also 20 percent, is $89.30.

Lupron can be given three ways: in a one-month dose (7.5 milligrams) billed as one unit, in a three-month dose (22.5 milligrams) billed as three units, and in a four-month dose (30 milligrams) billed as four units.

Zoladex can be billed in two ways: a one-month dose (3.6 milligrams) billed as one unit, or a three-month dose (10.8 milligrams) billed as three units.

The key point to remember is that many carriers have adopted the minimal alternative rule, meaning they will pay for Lupron at the same price that they will pay for Zoladex. Because Lupron is much more expensive than Zoladex, that means the co-pay for the patient is much larger.

For commercial managed-care patients, the story may be quite different. Many of the HMOs will not cover Lupron at all, reports Borrero. Some require the patients to get their Lupron directly from the HMO pharmacy. And because the number of patients covered by HMOs has risen so much, even in a large practice, Lupron has become very costly. (In large practices, the Lupron is bought in bulk, so it costs much less than in small practices.)