Urology Coding Alert

CMS reaches out to confused urology Coders with the answer to its million-dollar question: How should coders treat claims for Lupron injections administered to SNF patients? Where to find this treasure: CMS' SNF learning network Web site.
 
The battle for skilled nursing facility (SNF) patient reimbursement has begun, and the only way to come out on top is to get a firm grip on which services fall under the SNF consolidated billing guidelines - and delineate the services that require you to code technical and professional components separately.
 
"CMS has a Web site dedicated to SNF education," says Jeane Capers, RHIT, coding compliance officer with West Texas Medical Associates in San Angelo. "The CMS site is www.cms.hhs.gov/medlearn/snfcode.asp." The site contains four files of CPT codes that can or cannot be billed directly to Medicare Part B, she says. Put the Files to Good Use: Locate Lupron The area that is giving coders the most difficulty is coding claims for Lupron administered to SNF patients. When your urologist provides services to a Medicare beneficiary in a Part A covered SNF stay, look up the codes in the four files for what the urologist provided to see where the services are listed - where you find the code will determine how you code the service.
 
You must report the supply of Lupron (J9217, Leuprolide acetate [for depot suspension], 7.5 mg), a drug that urologists frequently administer to their patients, to the SNF because it falls under the consolidated billing rules, Capers says. The same holds true for Zoladex (J9202, Goserelin acetate implant, per 3.6 mg), which must be billed to the SNF, not the carrier.
 
The coding translation: Do not attempt to get reimbursed by Medicare Part B for either the supply of the drug or the injection of the drug (96400, Chemotherapy administration, subcutaneous or intramuscular, with or without local anesthesia). Both the supply and the injection itself should be submitted to the SNF. You cannot separate the technical and professional components of these services.
 
"[Lupron and Zoladex] are typically administered infrequently and in a general practitioner's office," says Thomas Hoyer, director of CMS' Center for Medicare Management Chronic Care Policy Group. "They are not identified as being beyond the general scope of care that a SNF would normally furnish. Additionally, in identifying certain specific chemotherapy codes for exclusion from SNF consolidated billing, Congress has considered these two codes in the past but has not decided to add them to the exclusion list. Therefore, it is our determination that these codes continue to be subject to consolidated billing."
 
Also remember that you have to check with the nursing facility the same day that you render Lupron shots or any other services to the [...]