Stop Using 96402 for Lupron Injections in Noridian patients

Tue, Apr 12, 2011 --

Coding Updates

Now, post March 1, you need to apply the new rule

If your practice treats patients with insurance coverage through Noridian, you will need to remember a new chemotherapy drug administration rule from the Medicare Administrative Contractor (MAC). See to it that you are reporting Lupron injections properly for these patients in order to stay away from denials.

This will impact practices in Arizona, Utah, North Dakota, South Dakota, Wyoming, and Montana, with Noridian Administrative Services as their MAC.

Know the reason for the change

Now that March 1 is over, you will not be able to use administration code 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic) with some drugs as you have done previously.

As per information that Noridian first released on May 6, 2010 the preparation and administration of Gonadotropinreleasing hormones (GnRH) –  also known as luteinizing-hormonereleasing hormones (LHRH) – doesn’t meet the CPT manual requirements of the use of the chemotherapy administration codes.

According to a notice issued by Nordian, Medicare considers the use of the chemotherapy administration codes to properly describe the parenteral administration of only these drugs – J1745 Injection Infliximab and any non-GnRH drug/compound mentioned in the present HCPCS section ‘Chemotherapy Drugs J9000-J9999.

Now turn to 96372

How it impacts your practice: Ann Hayden, office manager at Urology Specialists in Phoenix says, “I bill 96402 when we give Lupron and Zoladex.”

Now you will no longer be able to report 96402 for the administration. According to Noridan, in place of chemotherapy drug administration codes 96401- 96549, you should select a code from the 96360-96379 code series.

New way: According to Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook,  it seems like Noridian (MAC) will suggest the use of the injection code 96372 in place of 96402 for GNRH analogues such as Lupron, Zoladex, and Trelstar.

Bad news: However, Hayden laments, “That’s the way I read their notice also but was hoping that I was wrong since the reimbursement is less on 96372 than for 96402.”

Here’s an instance: A patient visits your office for a Lupron injection. The urologist makes a clinical assessment through his examination (level-two E/M service) that the patient can continue to receive further doses of Lupron. This assessment calls for a separate charge.

Earlier you could report 99212-25 for the clinical assessment, 96402 for the Lupron administration and J9217 for the drug. Currently, for a Noridian patient, you would report 99212-25, 96372, and J9217.

Good tidings: Ferragamo says,The other MACs have not indicated any change as far as I know.”


Barnali is a medical coding and billing writer at TCI who has worked in the healthcare industry since 2009. She holds a master’s degree in English literature and a diploma in advertising and marketing. She enjoys writing about ICD-10 and Medicare compliance.

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