Oncology & Hematology Coding Alert

Question: When is it appropriate to bill Lupron, J9217 (Leuprolide acetate [for depot suspension], 7.5 mg), instead of Lupron, J9218 (Leuprolide acetate, per 1 mg)?

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Answer: It is first important to note that J9217 is for depot suspension and J9218 for an injection, which makes them distinctly different. Code J9217 requires the drug to be incorporated in a depot formulation that is a monthly intramuscular injection, while J9218 is a daily subcutaneous injection. The codes are not interchangeable.

However, there is an additional issue to consider. If two drugs are equal in efficacy, including different versions of the same one, practices should choose the lower-cost one. This is because Medicare does not cover the additional expense of the more costly drug since this extra cost is not attributable to an item or service that is medically reasonable and necessary. However, a drug that is less effective should not be chosen because it costs less.

Before using an expensive drug, practices should explore the use of an alternative that is clinically comparable. Choosing a similar medication must be determined on a patient-by-patient basis. According to the Physicians Desk Reference, the safety and efficacy of Lupron Depot do not differ from the injection form of the drug, making it a matter of physician choice. In addition, some oncology practices choose Zoladex, J9202 (Goserelin acetate implant, per 3.6 mg), because it is similar in efficacy and price to Lupron. If a patient responds to the Zoladex and the price is similar, there should be no reimbursement problem. If the patient does not respond well to one and the alternative is used, the patient record should indicate why the change was made to show medical necessity.