Medicare Compliance & Reimbursement

Check out these sticky new guidelines for ESAs.

The Centers for Medicare & Medicaid Services (CMS) will crack down on coverage for erythropoiesis stimulating agents (ESAs) used to treat anemia in patients who receive dialysis for end-stage renal disease (ESRD). Since CMS last updated its coverage, the Food & Drug Administration issued a "black box" warning, saying that large doses of ESAs are risky for ESRD patients with hemoglobin levels above 12 g/dL.

Effective next January, Medicare will continue to pay the same for ESAs for patients with hemoglobin of between 10 and 12 g/dL. But for patients whose levels rise above 13 g/dL, you should reduce the patient's dosage by 25 percent and append the GS modifier. This modifier shows that the provider has reduced the patient's ESA dosage in response to the hemoglobin/ hematocrit level. And if the hemoglobin is above 13 for more than three months, the provider should reduce dosages by 50 percent.

CMS also says it won't pay for dosages of epoetin alpha (Epogen) over 400,000 IUs per month, or higher doses of darbepoetin alpha (Aranesp) than 1200 mcg per month.