Q.
Will leuprolide acetate (Lupron) reimbursement fall by 20% in 2005? When will it take place? And what will the reimbursement be?
A.
The Medicare payment for leuprolide fell significantly more than 20% on January 1. In the 44 states that have adopted the least costly alternative (LCA) methodology, the payment limit will be $189.79 (the payment for goserelin acetate [Zolodex]) for the first quarter. In the five states that chose not to adopt the LCA payment methodology (Wisconsin, Illinois, Michigan, Minnesota, and Montana), leuprolide will pay $253.13 and goserelin will continue to pay $189.79. A sixth state, Utah, recently decided to suspend LCA for the next 6 months.
Remember, these payments will probably change quarterly as the average sales price changes. Also, since the decision on LCA payment is made by the carrier, that could change in your state at any time. Check with your carrier to determine payment in your state.
Q.
I have heard that the injection codes have changed. How should I charge for the injection of leuprolide?
A.
The injection codes also changed as of January 1. Use G0356 for injection for leuprolide, goserelin, etc. This will replace code 96400 (or 90784 for some). Also, for injection of antibiotics, testosterone, and other therapeutic drugs, use G0353 (replaces 90784). The rules for charging an office visit did not change. If the physician evaluates the patient and provides a medically necessary service during a visit in which the G0356 is charged, then charge the appropriate level of service with a -25 modifier. You cannot charge 99211 on the day of the injection. You cannot charge for an office visit and G0353 on the same day.
Q.
I read in a newsletter that, by asking a cancer patient three questions, I could be paid an extra $130.00 each visit. Is this true? Can I charge this in addition to my injection codes when I administer leuprolide?
A.
An article in one of the newsletters suggested that physicians could ask a cancer patient a few questions about pain, nausea, etc., and receive payment for an extra $130.00. This was a reference to a special demonstration project funded by the Centers for Medicare & Medicaid Services. Unfortunately, payment is restricted to patients receiving chemotherapy by IV infusion or IV push. Any physician can participate and bill the new G codes (G9021-G9032) if they’re administering chemotherapy intravenously. However, these codes cannot be billed with LHRH injections.
Q.
What is the proper way to get reimbursement for using a holmium laser or YAG:Diode laser for procedures at the office (for bladder tumor) and ambulatory surgical facilities? Is there a better way besides billing the 99070, such as S2070, which I just found recently?
A.
Since you did not mention specifically the procedures you want to code in the first question, I have assumed that they are part of the second question, which has to do with getting paid for procedural supplies, eg, the laser equipment and other supplies, in the office and ambulatory surgical center.
If the patient is a Medicare patient, you cannot charge separately for supplies and equipment for procedures performed in the office.
Prior to using the YAG laser or other expensive equipment in the office, you want to be sure that the expenses will be covered. This can be checked by referring to the Federal Register, the fee schedule issued by the Medicare carrier, or another data source such as http://AUACodingToday.com/. Search for the appropriate code, and check the amount of payment for both facility and non-facility payment.
For example, bring up 52647 (non-contact laser coagulation of the prostate) on http://AUACodingToday.com/. Click on fee schedule, and look up payment for non-facility (Medicare lingo for procedures performed in the office or similar outpatient setting). You’ll find that the non-facility payment is much higher than the facility payment. That higher payment is to pay you for the laser equipment and all the supplies needed to perform the procedure in the office.
Now look at 52648 (contact laser vaporization with or without transurethral resection). You will find that the non-facility and facility fees are the same. That clearly tells you that that procedure has not been approved to be performed in the office, and you will not be reimbursed for the cost of supplies, equipment, etc. Therefore, for a Medicare patient, you would not want to perform the procedure in the office. You can apply this check for payment to any Medicare procedure.
For private payers, you want to be sure they are going to reimburse you for the cost before performing the procedure. Prior approval with a contractual payment agreement is preferable. If they have agreed to pay you Medicare rates, be sure they are paying you the non-facility fee.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
