Urology Coding Alert

Your Medicare contractor can't use the least costly alternative payment method anymore -- so keep an eagle eye on your EOBs.

If your practice gets hit with reduced reimbursement every time you submit a Medicare claim for Lupron, you're in luck. CMS determined they will no longer enforce their least costly alternative (LCA) policies. Make sure you have all the details to ensure your practice gets the money you deserve.

Expect Full Pay as of April 19, 2010

In February, CMS lost a lawsuit regarding its LCA policy. As a result, all Medicare contractors must pay for Part B drugs according to the particular drug the patient actually received, not the price of the lowest cost alternative drug for which they were paying in the past.

The history: The American Association of Clinical Urologists (AACU, www.aacuweb.org) posted the resulting policy update on its Web site. According to the AACU site, "This change comes after a ruling in December, where the U.S. Court of Appeals for the D.C. Circuit sided with a Medicare beneficiary regarding her treatment option. The case of Hays v. Sebelius involved Medicare denying a patient a prescribed treatment  or her serious lung disease. Medicare, in complete contrast to the physician's advice, decided to pay for the Least Costly Alternative (LCA). The court ruled in favor of the plaintiff, and the decision by Medicare was overruled." You can also read the entire legal case document on the American Urological Association (AUA) Web site at www.auanet.org/content/legislative-and-regulatory/washington-news/alerts/lca-09.pdf.

Timeline: All Medicare contractors are to be in compliance with this decision as of April 19, 2010, regarding the luteinizing hormone-releasing hormone (LHRH) analogs. "Our carrier, Cahaba, posted on their Web site on Friday that they would no longer apply the LCA policy as of April 19, 2010, in accordance with CMS ruling," says Robin Shaw, billing manager for the Urology Surgery Center of Savannah in Georgia. Don't Alter Your Coding

Old way: In the past, most Medicare carriers adjusted your payment for drug codes down to the drug within the same classification with the lowest Average Sales Price (ASP), also known as applying the LCA. When there are two available drugs with equivalent medical efficacy, Medicare would only reimburse for the least expensive drug, regardless of the actual drug your urologist uses, explains Chandra L. Hines, business office manager at Capital Urological Associates in Raleigh, N.C. For example, Trelstar became the LCA for LHRH drugs in January 2007. So regardless of whether your urologist used Lupron (J9217, Leuprolide acetate [for depot suspension], 7.5 mg), Zoladex (J9202, Goserelin acetate implant, per 3.6 mg), or Trelstar (J3315, Injection, triptorelin pamoate, 3.75 mg), Medicare reimbursed you at the lower fee for Trelstar.

New way: Now, when you report J9217 for a Lupron injection,your Medicare contractor should pay you for Lupron, not the LCA (Trelstar), Hines says.

The benefit: "This should have quite an impact on urology practices because the reimbursement for J9217 is significantly higher per unit than what has been deemed the LCA drug (J3315) -- approximately $56.31 per unit fee increase when getting reimbursed for J9217 over J3315," Shaw says. Practices with a large number of prostate cancer patients "could definitely see a positive impact on revenue this quarter resulting from this ruling," she adds.

Monitor Carrier Updates and Fight for Your $$

You need to be diligent and review your explanation of benefits and payment statements to ensure your contractor isn't still using the LCA payment policy.

Beware: "Our carrier was continuing to apply the LCA to Lupron and pay us for Trelstar, which was against the ruling of the lawsuit," Shaw laments.

Best bet: "Basically practices need to first go to their carrier's Web site to see if they have anything posted about the ruling," Shaw says. "Then, of course, practices need to be sure they are looking at their Medicare explanations of benefit to ensure they are getting proper reimbursement for the drug they gave."

(See the chart below for the LHRH analog therapy drugs that have been subject to LCA reductions in the past. Watch your claims for proper payment on these drugs under the new ruling.)