Medicaid Billing of Depo-provera

on Monday, 18 February 2013. All News Items | AL Medicaid | Billing

The HCPCS codes for the drug medroxyprogesterone acetate changed at the beginning of this year. Medroxyprogesterone acetate is known by the brand names of Depo-Provera, Provera, Prempro, Depo-Provera Contraceptive, Cycrin, Lunelle, Premphase, Amen, depo-subQ provera 104, Curretab, Premphase 14/14.

The “old” codes (for dates of services prior to January 1, 2013) were:

  • J1051 – Injection, medroxyprogesterone acetate, 50 mg*
  • J1055 - Injection, medroxyprogesterone acetate for contraceptive use, 150 mg*

For dates of service on and after January 1, 2013, the following code replaces the above codes:

  • J1050, Injection, medroxyprogesterone acetate, 1 mg

 

As a result of this code change, Alabama Medicaid is requiring the use of a modifier to distinguish between use of the drug for contraceptive use and other (non-contraceptive) uses. Modifier FP is used to indicate the injection of the drug for contraceptive use and modifier U1 indicates non-contraceptive use. The Medicaid Alert also lists the following restrictions for usage.

 

Contraceptive Use Restrictions (J1050-FP)

  • Limited to female recipients 10-55 years of age
  • Dosage of 104 – 150 mg per injection
  • Allowed once every 70 days
  • Claim must include a contraceptive management diagnosis code

 

Non-contraceptive Use Restrictions (J1050-U1)

  • Covered for recipients of all ages
  • Limited to 1000 mg per injection
  • Claim must not include a contraceptive management diagnosis code

 

Providers should report the drug units based on the new “per 1 mg” description – for example 150 mg would be billed with 150 units, 500 mg with 500 units. Alabama Medicaid reimburses J1050 at $ 0.20 per unit (per mg). Claims for J1050 billed without a modifier will be denied by Alabama Medicaid. See the link above for complete information.

 

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

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