FIRST COAST SERVICE OPTIONS
LOCAL COVERAGE DETERMINATION
CODING GUIDELINES
Contractor’s
Determination Number
J1950
Contractor Name
First Coast Service
Options, Inc.
Contractor
Number
09102 –
09202 – Puerto Rico
09302 –
LCD Title
Leuteinizing
Hormone-Releasing Hormone (LHRH) Analogs
Coding
Guidelines
An acceptable
Advanced Beneficiary Notice (ABN) of Medicare’s possible denial of payment for
the additional expense of the more expensive drug must be given to the patient
if the provider does not want to accept financial responsibility for each
injection of the more costly agent when there is a clinically comparable less
expensive agent available. Use the GA modifier to indicate that the ABN
statement is on file and use the GZ modifier to indicate that an ABN statement
is not on file
If there is
documentation to support the medical necessity for the use of the more costly
agent (e.g. allergy) and the provider wishes to have this documentation
reviewed, FCSO recommends that providers put the following statement into block
19 or it’s electronic equivalent on CMS form 1500: Documentation of medical
necessity available for review.
* Please note that providers are not
required to populate block 19 for claim development if they do not wish to.
Leuprolide
Acetate J1950
Bill 1 unit for the 3.75 mg monthly injection
or 3 units for the 11.25 mg injection once every three months. Administration
code 96402 should be billed J1950.
Leuprolide Acetate (for depot suspension)
J9217
Bill 1 unit for the 7.5 mg once a month dose;
Bill 3 units for the 22.5 mg once every three (3) months dose; Bill 4 units for
the 30 mg once every four (4) months dose and Bill 6 units for the 60 mg once
every six (6) months dose. Administration code 96402 should be billed for J9217.
Leuprolide Acetate Implant J9219
Bill one (1) unit once every 12 months. The
following administration codes may be billed with J9219: Insertion of implant-
11981; Removal of implant –11982; Removal and insertion of implant-
11983.
Triptorelin pamoate J3315
Bill one (1) unit for the once a month 3.75
mg injection; Bill three (3) units for the once every three months 11.25 mg
injection. Administration code 96402 should be billed for J3315.
Goserelin acetate implant J9202
Breast Cancer and endometriosis: Bill one (1)
unit for each 3.6 mg injection. Administration code 96402 should be billed with
J9202.
Prostate Cancer: Bill one (1) unit for each
3.6 mg injection and bill three (3) units for the once every three months 10.8
mg injection. Administration code 96402 should be billed with J9202.
Histrelin implant J9225
Bill one (1) unit once every 12 months. The following administration codes may be
billed with J9225: Insertion of implant- 11981; Removal of implant –11982;
Removal and insertion of implant- 11983.
Other Comments
N/A
Revision History
|
Date |
Revision |
|
02/02/2009 – |
Original |
Document formatted:
12/29/2008 (xx/st)