Urology Coding Alert

Question: Under what circumstances can we be paid in full for Lupron?

Delaware Subscriber

Answer: In states where you are mandated to follow the least costly alternative (LCA) principle, Medicare will never pay the full allowable amount for Lupron (J9217). However, in many of the LCA states, the patient can be billed the difference between the cost of the Lupron and the cost of Zoladex (J9202) if there is a properly executed advanced beneficiary note (ABN) on file. The ABN must specifically state that Medicare may deny payment for the higher priced drug, and that the patient understands he or she would be responsible for paying the difference. Report J9217. Medicare will process for payment using the allowable for Zoladex. Many offices have stopped using Lupron, and are now using Zoladex exclusively. They found that HMOs were refusing to pay for Lupron, and the patient would have to pay for this expensive drug on his or her own. Patients prefer Lupron because its a regular intramuscular injection in the buttock, whereas Zoladex is injected subcutaneously in the abdomen, often producing local discomfort. There is no difference in the efficacy of Lupron and Zoladex. The urologist should check with the insurance carrier for guidelines on this issue.


Answers contributed by Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York, Stonybrook; and Sandy Page, CPC, CCS-P, co-owner, Medical Practice Support Services, Denver.