Oncology & Hematology Coding Alert

Answer: Zoladex (goserelin acetate implant) is used to treat advanced forms of prostate cancer in men, and to treat advanced forms of breast cancer in women. It is also used to relieve the pain and discomfort of endometriosis in women. In men, Zoladex decreases the blood levels of testosterone while in women it decreases the blood levels of estrogen. Dosage of Zoladex implants contains 3.6 mg of medication, which is placed just under the skin of the upper abdominal wall. To code the drug, use HCPCS level II code, J9202, goserelin acetate implant, per 3.6 mg.

Enter 1 in the unit column for a one-month injection, report 3 in the unit column for a three-month injection. The following ICD-9 codes are considered for medical necessity when Zoladex is used for prostate cancer:

185 malignant neoplasm of prostate;
198.82 secondary malignant neoplasm of genital
organs;
233.4 carcinoma in situ of prostate.

Using 90782 may not be appropriate if the physician provides an evaluation and management (E/M) visit at the same time. HCFA has coding guidelines regarding the drugs Zoladex and Lupron, J9217, leuprolide acetate (for depot suspension), 7.5 mg, which are both used for the treatment of prostate cancer.

If two services are clinically comparable, Medicare does not cover the additional expense of the more costly service, because this additional expense is not attributable to an item or service that is medically reasonable and necessary. HCFA also states there is no demonstrable difference in clinical efficacy between Zoladex and Lupron for the treatment of prostate cancer. Therefore, Medicare will pay for the least costly drug. If Medicare denies payment for the additional expense of the more costly drug the beneficiary can be held liable for the denied charge if an advanced beneficiary notice (ABN) is signed for each injection. Remember to use modifier -GA to indicate that the ABN is on file.

The beneficiary liability must not exceed the difference in the allowance between the two drugs. If there is a legitimate medical indication that requires the use of the more expensive drug, Medicare may consider payment if documentation of the medical necessity accompanies the claim. The documentation should include: history and physical, office/progress notes, and a letter of medical necessity from the physician.

Laurie Castillo, MA, CPC, president of American Association of Procedural Coders Northern Virginia Chapter, president of Physician Coding & Compliance Consulting, both in Manassas, Va.., answered You Be the Coder.