lupron HCPC codes?

tonplair@gmail.com

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what HCPC code will we use for lupron 11.25 mg for a patient that they are giving for breast cancer. Would you use the J9218 1mg per unit and code 12 units or do we use J9217 and code it that way. Could some one help me?
 

lmartin

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Lupron HCPCS Code

I would suggest that you check the LCD with your local MAC to see what they have outlined in their policy (even if your patient is not a Medicare patient as so many commercial insurances follow the Medicare policies). The RACS are taking back alot of money right now when what they consider to be the wrong code was used. I have noted that J9217 is typically the code to be used for male patients. Hope that helps :)
 

relong

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find out from your clinical staff which Lupron they're using. j9217 is depot suspension which is slower acting and j9218 is not depot which is faster acting, they aren't the same thing.
 
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suemt

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I realize this is an old post, but maybe someone like me will come looking and find some useful information. This is from an OIG Compliance Review:

http://oig.hhs.gov/oas/reports/region7/71201119.pdf

Medicare Compliance Review of Community Medical Center for Calendar Years 2010 and 2011 (A-07-12-01119), Page 3

INCORRECT HEALTHCARE COMMON PROCEDURE CODING SYSTEM CODE FOR LUPRON INJECTIONS
Section 1833(e) of the Act precludes payment to any provider of services or other person without information necessary to determine the amount due the provider. The Manual, chapter 1, ?80.3.2.2, states: ?In order to be processed correctly and promptly, a bill must be completed accurately.? The Manual, chapter 17, ?90.2.A, states: ?It is ... of great importance that hospitals billing for [drugs] make certain that the reported units of service of the reported HCPCS code are consistent with the quantity of a drug ... that was used in the care of the patient.? If the provider is billing for a drug, according to chapter 17, ?70, of the Manual, ?[w]here HCPCS is required, units are entered in multiples of the units shown in the HCPCS narrative description. For example, if the description for the code is 50 mg, and 200 mg are provided, units are shown as 4 ....?

The Food and Drug Administration (FDA) identifies and reports drug products with a universally used unique, three-segment number called the national drug code (NDC). Each quarter, CMS provides Medicare contractors with an updated listing that cross-references the NDC to the drug name, billing units, and HCPCS code.

Lupron is a drug commonly used to treat hormone-dependent cancers. The FDA approved Lupron for the treatment of disorders relating to the uterus and for the treatment of prostatic cancer. According to the NDCs in effect during our audit period, Lupron was available for the treatment of: (1) disorders relating to the uterus, in doses of 3.75 mg once a month or 11.5 mg once every 3 months, and was linked to HCPCS code J1950; and (2) prostatic cancer, in doses of 7.5 mg once a month, 22.5 mg once every 3 months, or 30 mg once every 4 months, and was linked to HCPCS code J9217.

For all 57 selected claims that we sampled, Community incorrectly billed Medicare for Lupron injections. Specifically, Community billed Medicare using HCPCS code J1950 when its documentation showed that according to administered dosage, Community should have billed Medicare using HCPCS code J9217.
 
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