Urology Coding Alert

Occasionally, a prostate cancer patient will be in a hospice program but seen by his urologist. Coders wonder how to bill for Lupron injections, which are very costly. The medication is very expensive, says Ruth Borrero, assistant billing manager for Urology Associates, a six-provider practice in Manhasset, N.Y. But Medicare will pay for 80 percent of itas long as its Zoladex and not Lupron. This is because Medicare requires the least costly alternative.

The Health Care Financing Administration (HCFA) has mandated that Medicare reimbursement for Lupron be limited to the approved amount for Zoladex, a less expensive medication, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services in Denver. Page, who specializes in urology coding , notes that if patients sign a waiver, they can be charged the additional cost of the Lupron. Some commercial payers and pharmacy benefit plans may have the same requirement.

Zoladex is less money, but a lot more uncomfortable, says Borrero. Thats why patients are willing to pay the extra for the Lupron.

Note: The needle must be fairly large for Zoladex, because Zoladex is injected in pellet form. Even though Zoladex is administered subcutaneously, which should make it less painful than Lupron, which is administered intramuscularly, the 14-gauge needle may make the injection more uncomfortable. However, Xylocaine is administered first to numb the skin.

If the patient is in a hospice facility, the facility will bill and be reimbursed for the Lupron, says Page. If the patient is receiving hospice benefits at home and the urologist supplies the medication, the urologist can bill Medicare for the drug. Lupron is J9218 (per 1 milligram) and J9217 (per 7.5 milligrams); Zoladex is J9202 (per 3.6 milligrams).