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
Luteinizing
Hormone-Releasing Hormone (LHRH) Analogs
Coding
Guidelines
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 |
|
04/19/2010 |
1 - Revision to
remove all language pertaining to the least costly alternative (LCA)
provision. The effective date of this
revision is based on process date. . (The effective date for the LCD revision
has been revised to reflect the date of the CMS instruction to contractors
for removal of LCA language. The
revised effective date is 04/19/2010). |
|
02/02/2009 – |
Original |
Document formatted: 07/08/2010
(SS/et)