Postpartum Drug Challenges Medical Coders

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  • March 20, 2019
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Postpartum Drug Challenges Medical Coders

There is a lot of excitement about a new drug for women suffering from postpartum depression, but Sage Therapeutics’ Zulresso will present challenges for medical coders, their employers, and patients.

First Postpartum Depression Drug

Zulresso is the first drug developed specifically for postpartum depression. Often un- or misdiagnosed, postpartum depression (F33.0), affects an estimated national average of 11.5 percent of mothers per year, although some states report a range from 8 to 11 percent. While many symptoms are similar to other onsets of depression, it can impair a mother’s bonding with her child and may lead to thoughts of harming herself or the baby.  Treatment has been limited to therapy, monoamine oxidase inhibitors (MAO), and selective serotonin  reuptake inhibitors (SSRI).

Answering Patients Questions

The Food and Drug Administration (FDA) approved the allosteric modulator of GABAA receptor, which means it prompts the GABA receptor in the brain to calm nerve activity, for use beginning mid-March. A wholly new class of drugs, Zulresso, while approved, requires a monitoring period after women receive the injection. This means the following:

  • The patient receives the medicine through infusion.
  • The patient must be observed for the 2.5 days.
  • The patient is responsible for the cost of the drug, its administration, and inpatient care.

According to the Associated Press, Sage said the drug will cost $34,000 per dose without insurance.  A check with several insurance companies indicates Zulresso isn’t in the pharmacopeia at this writing.
Be sure to check with the patient’s payer if before you submit this drug or answer a patient’s question. A specific HCPCS Level II code doesn’t exist yet. Since there are many venues for  the patient’s infusion, check with Sage and payers to confirm how the provider is referring her and to where. Different rules and coverage apply for facility outpatient, observation, infusion, and inpatient care.

Oral Postpartum Drug Soon

Sage is studying another product, SAGE-217, for depression that uses the same mechanism. This drug, if approved by the FDA, will be oral, nixing the infusion and inpatient costs.

Brad Ericson
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About Has 361 Posts

Brad Ericson, MPC, CPC, COSC, is a seasoned healthcare writer and editor. He directed publishing at AAPC for nearly 12 years and worked at Ingenix for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

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