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Thread: Billing Medicare for Depo-Provera

  1. #1

    Default Billing Medicare for Depo-Provera

    AAPC: Back to School
    Hi, I am not too familiar with Medicare billing. Although I have billed commercial insurances before, Medicare billing is fairly new to me. Has anyone out there billed out Depo-Provera for a patient who has Medicare? This patient is only 35 years old. I have read on supercoder.com (dtd 2000), that Medicare does not cover the cost of Depo-Provera injections when used as a contraceptive. If this is so, then how would I code the injection for a Medicare patient? Please advise.........thanks!

  2. #2


    If she is 35 years old and on Medicare, I would assume she has some serious health issues.
    Can you use her medical diagnosis to prove that it isn't being used for contraception? It is being used for birth control, yes, but because of other health issues?

    i.e. if she has End Stage renal Disease, for example, obviously getting pregnant isn't an option for her.

    Just a suggestion.

  3. #3

    Default Billing Medicare for Depo-Provera

    My OB/Gyn office has had the same issue with medicare and depo. Check the medical records to make sure exactly why patient is receiving the injections. If the patient is truly receiving the depo shots for contraception then you would have no choice but to bill HCPCS code J1055 with the contraceptive management diagnosis. However, some physicians give a depo shot to a patient to help manage/reduce abnormal bleeding or heavy menstrual cycles. In that case you would bill J1051 for the depo with the medical issue diagnosis. In either case, I would hope the physicians office completed an ABN form and had patient sign acknowledging that I may not be covered and she would be responsible if medicare does not cover. If the physicians office did have complete the ABN be sure you bill with a "GA" mod to let medicare know they can process to patient responsibility if not a covered item.

    Hope this helps you.

  4. #4

    Red face depo provera

    I'm doing follow up and can anyone tell me if they find insurance carriers denying the depo ?

  5. #5


    Our clinic noticed that insurances were not paying for the shot at all or were paying very little. (not enough to cover the cost of the medication) Since then we have narrowed down who pays and who doesn't pay. The ones that do NOT pay we are having the patients pick up the meds at the pharmacy and then come to the clinic to have it administerd. Yes this is not ideal for the patient, but we are not left holding the bag so to speak. We have also found that one business has for their employees a separate insurance policy for contraceptives only due to the health care act. This is yet anohter thing to check as well.

  6. #6


    In Texas depo is not covered at all. We send our pts to the pharmacy to pick it up and we charge them a self pay fee for giving the injection. We put it on our ABN that depo is not covered under medicare. Every private insurance company is different. I have to call on all of them we give. Some pay some do not.


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