Regina Magnani, RHIT, Clinical/Technical Editor
The Office of Inspector General recently identified two hospitals that received hundreds of thousands of dollars in overpayments for provision of leuprolide acetate. If the hospitals had understood how the patients’ diagnoses affected coding and coverage, they could have avoided reimbursement headaches.
Leuprolide acetate is a long-acting synthetic analog of naturally occurring gonadotropin-releasing hormone. The synthetic analog is more potent than the natural hormone. An injection of leuprolide acetate depot solution results in an initial stimulation followed by prolonged suppression of pituitary gonadotropins and decreased secretion of gonadal steroids (a depot suspension is a drug encased in microspheres that remain at the injection site and gradually release the drug). The dose must be repeated quarterly for continued hormone suppression. The effect is reversible upon discontinuation of the drug.
The packaging does not really provide a clue as to which HCPCS Level II code to report as the same doses can be used for different indications. When used for advanced prostate cancer dosages can be 7.5 mg for one month, 22.5 mg for three months, 30 mg for four months, and 45 mg for a six-month dose. The 7.5 mg dose suppresses gonadal steroids, which includes ovarian and testicular steroids. This in turn inhibits the growth of hormone-dependent tumors of the prostate, ovaries, and breast.
When used to treat endometriosis or uterine leiomyomata, doses of 3.75 mg for one month and 11.25 mg for three months are usually used. Central precocious puberty is usually treated with the leuprolide acetate depot-pediatric formulation with a dose of 7.5 mg, 11.25 mg, and 15 mg for one month, and 11.25 mg or 30 mg for three months.
Two HCPCS Level II codes represent this drug:
J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 MG
J9217 Leuprolide acetate (for depot suspension), 7.5 mg
While these descriptions are not clear about the indications, there are numerous local coverage determinations that state that J9217 is used for cancer-related diagnoses and J1950 for non-cancer-related indications.
The OIG has cited numerous hospitals for incorrectly reporting the drug codes. Recently two hospitals were identified as incorrectly reporting HCPCS Level II code J1950, reimbursed at double the rate of J9217, for injections provided to its cancer patients. Overpayments of $257,682 and $447,776 were identified. It seems the only way to avoid using the incorrect HCPCS Level II code is to be aware of the patient’s diagnosis.