OIG shouldn't fine for switching LHRH schedules

July 1, 2005

The government has no way, nor should they, of determining what's best for that patient.

A: I do not think the OIG, the watchdog of the Medicare program, will penalize or fine anyone for switching from one drug or one formulation, such as a 3-month to a 6-month or vice-versa. After making such a bold statement, I should explain my reasoning. There are several overriding facts that we should keep in mind:

You also have to figure ways that you can continue to provide good patient care, and that includes providing the drugs your patients need. You cannot afford to lose money and continue to provide those services. Therefore, you have to consider the economics of one drug versus another. Actually, in my opinion, you can justify changing drugs based on the economics.

I cannot say with certainty that the OIG will not take action if you switch drugs, but I do not think it will, or legally can, do so.

Q: We have been billing Bacillus Calmette-Guerin with code J9031 along with bladder instillation code 51720. On one of our recent billings, Medicare denied the 51720 as included with J9031. Has there been a change in billing for BCG?

A: J9031 represents a request for payment for the drug only. The installation is not bundled into the drug. Therefore, charge for the installation separately, and you should be paid by Medicare. Appeal the denial.

Private payers, at times, do not pay when they should, even if the denial is not covered by their contract.

Q: Occasionally, an extracorporeal shock wave lithotripsy procedure is not performed because the previously visualized stones are not seen at the time of treatment. The patient has been anesthetized, a fluoroscopic search is conducted, but treatment is not accomplished. Is there any code to allow charges for time spent by the urologist?

A: Yes. You should charge for the procedure that was started but was not completed, in this case, the ESWL, with a –52 modifier (50590–52), and decrease the fee to the amount you think is appropriate. Beware. By charging for the ESWL, even with the –52 modifier, you will create a 90-day global, and the fee should take that into consideration.