Medicaid Billing of Depo-provera
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