Urology Coding Alert

The bad news: Lower allowances for Zoladex, Lupron and Viadur

Good news: On Oct. 1, you'll be able to report 84152 (Prostate specific antigen [PSA]; complexed [direct measurement]), 84153 (... total) or 84154 (... free) for patients with BPH (ICD-9 code 600.01, Hypertrophy [benign] of prostate with urinary obstruction).

The change, which CMS will include in the October 2004 release of the edit module for clinical diagnostic laboratory services, will add 600.01 to the list of approved diagnoses for PSA tests.

According to a recent decision memo, CMS "has determined that ICD-9-CM code 600.01, benign prostate hypertrophy with urinary obstruction, flows from the existing narrative for conditions for which prostate specific antigen (PSA) is reasonable and necessary."

"We intend to modify the NCD [national coverage determination] for PSA testing to include this code in the list of 'ICD-9-CM Codes Covered by Medicare' for this service," the decision memo continues.

Previously, without the ability to report a BPH diagnosis code, coders had to link PSA tests to BPH symptoms, such as 788.20 (Retention of urine, unspecified) and 788.43 (Nocturia).

Urology practices and coders should be pleased by CMS' decision, says Pattye Olmack, owner of Your Medical Billing and Consulting Service in Calabasas, Calif. "I think the more codes that they include [in PSA testing], the better," she says. With the urologists she works with, "for venipuncture charges, nearly all patients have the diagnosis of BPH."

New ICD-9 Code Results in Revised NCD

Code 600.01 was introduced in October 2003 to add a fifth-digit requirement to the existing code 600.0 (Hypertrophy [benign] of prostate). CMS does not mention the other new code, 600.00 (Hypertrophy [benign] of prostate without urinary obstruction), in the decision memo.

The memo was the result of a coding analysis for expansion of ICD-9-CM codes for the PSA NCD. The addition of the new code made it unnecessary to code BPH and urinary obstruction separately, CMS says. Thus, they say, "the new code 600.01 flowed from the narrative indications for PSA and should be added to the list of ICD-9-CM codes covered for that service."

The PSA test NCD lists the following as an indication for a diagnostic PSA testing: "PSA is of proven value in differentiating benign from malignant disease in men with lower urinary tract signs and symptoms (e.g., hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia and incontinence) as well as with patients with palpably abnormal prostate glands on physician exam, and in patients with other laboratory or imaging studies that suggest the possibility of a malignant prostate disorder."

"Coverage for this code will begin for services furnished on or after Oct. 1, 2004," CMS says.

Note: To read the change request, visit the Web site www.cms.hhs.gov/manuals/pm_trans/R225CP.pdf.

CMS Reduces Payment for Urologic Drugs in 2005

Now the bad news: Expect your reimbursement for Lupron and Viadur to go down about 55 percent in 2005.

The proposed physician fee schedule and new drug pricing, published in the Federal Register on August 5, lists the estimated calendar-year 2005 allowance for Zoladex (J9202, Goserelin acetate implant, per 3.6 mg) at $234.28, a 38 percent drop from the 2004 allowance, $375.99.

Reimbursement for Lupron (J9217, Leuprolide acetate [for depot suspension], 7.5 mg) will drop 53 percent in 2005, from $500.58 to $234.28. The estimated allowance for Viadur (J9219, Leuprolide acetate implant, 65 mg) drops to $2,190.71 in 2005, a 55 percent decrease from the 2004 allowance of $4,831.40.

Provider groups are already protesting, but, in a July 27 conference call with reporters, CMS Administrator Mark McClellan said some of the cuts are balanced by increases in the separate fees physicians receive for administering the drugs.

But although the reimbursement for 96400 (Chemotherapy administration, subcutaneous or intramuscular, with or without local anesthesia) has risen from the 2002 rate of $5.07 to the current rate of $64.07, in 2005 it will fall to $51.14.

Payment Reductions Could Bring Clinical Changes

Rosemary Russell, CPC, coding specialist at Maine Urology Associates of Bangor, says the allowance reductions will probably change how urology practices serve their patients. "The patients will end up not having the shots in the physicians' offices," she says. Overhead costs may make it unprofitable to inject patients in the office. "We may end up sending them to a cancer care center," Russell says.

Both physician groups and CMS have said the fees were sometimes too low, but, McClellan said: "Now we have new tools to pay appropriately for each drug and the services that go along with them, rather than having an overpayment for drugs subsidize an underpayment for services."

Note: To read the relevant Federal Register entry, visit http://www.access.gpo.gov/su_docs/fedreg/frcont04.html and click on "Thursday, August 5, 2004."