Urology Coding Alert

Apply the new rule to claims after March 1.

If your practice sees patients with insurance coverage through Noridian, you'll need to take note of a new chemotherapy drug administration rule from the Medicare Administrative Contractor (MAC). Ensure you're properly reporting Lupron injections for these patients before you start seeing denials.

This will affect practices in Arizona, Utah, North Dakota, South Dakota, Wyoming, and Montana, with Noridian Administrative Services as their MAC.

Learn the Reason for the Change

As of March 1, 2011 you won't be able to use administration code 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic) with some drugs as you have in the past.

According to information that Noridian first released on May 6, 2010, the preparation and administration of Gonadotropinreleasing hormones (GnRH), also known as luteinizing-hormonereleasing hormones (LHRH) does not meet the CPT manual requirements of the use of the chemotherapy administration codes.

Noridian issued a notice that stated: "Medicare considers the use of the chemotherapy administration codes to appropriately describe the parenteral administration of the following drugs ONLY:

• J1745 Injection Infliximab
• Any non-GnRH drug/compound listed in the current HCPCS section 'CHEMOTHERAPY DRUGS J9000-J9999.' Examples of GnRH and analogs include but are not limited to J9217 and J9218."

Turn To 96372 Now

How it affects your practice: "I bill 96402 when we give Lupron (J9217, Leuprolide acetate [for depot suspension], 7.5 mg) and Zoladex (J9202, Goserelin acetate implant, per 3.6 mg),"says Ann Hayden, office manager at Urology Specialists in Phoenix.

You'll no longer be able to report 96402 for the administration. Instead of chemotherapy drug administration codes 96401- 96549, you should choose a code from the 96360-96379 code series, according to Noridian.

New way: "It looks like Noridian (MAC) will suggest the use of the injection code 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) instead of 96402 for GNRH analogues such as Lupron, Zoladex, and Trelstar," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

Bad news: "That is the way I read their notice also but was hoping that I was wrong since the reimbursement is less on 96372 than for 96402," Hayden laments.

Example: A patient comes to your office for a Lupron injection. The urologist makes a clinical assessment through his examination (level-two E/M service) that the patient can continue to receive further doses of Lupron. This assessment warrants a separate charge.

In the past you would have reported 99212-25 (Office or other outpatient visit for the evaluation and management of an established patient ... Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for the clinical assessment, 96402 for the Lupron administration and J9217 for the drug. Now, for a Noridian patient, you would report 99212-25, 96372, and J9217.

Good news: "The other MACs have not indicated any change as far as I know," Ferragamo says.