Urology Coding Alert

Question: Does the J code for Lupron include both the cost of the drug and the time the physician, nurse or tech took to administer it? Or are there multiple codes used for an injection of Lupron at a doctor's office? Should I be using an E/M code along with the J code? What if a nurse gives the injection?

Massachusetts Subscriber

Answer: Code J9217 (Leuprolide acetate [for depot suspension], 7.5 mg) represents the drug supply only. Code 96400 (Chemotherapy administration, subcutaneous or intramuscular, with or without local anesthesia) represents the Lupron administration. Some Medicare carriers require 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) instead of 96400, even though J9217 appears in the Chemotherapy Drug section of the HCPCS book.

You should only report a separate evaluation and management services code when you provide a separately identifiable E/M service. And if a nurse is giving the injections, don't report those services separately. Effective Jan. 1, 2004, the NCCI included the "nurse-only visit" CPT code 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) in 96400. The NCCI edits include a status indicator of 0, which means you cannot bill them separately under any circumstances.

But if the urologist makes an assessment to determine whether further doses of Lupron can be administered, this assessment warrants a separate charge. You can use established patient office visit codes 99212-99215, depending on the work your urologist performs. A new edit for payment of E/M services for 2004 requires you to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to codes 99212-99215 if you're billing them with 96400. Code the above scenario 99212-25, 96400 and J9217.