Oncology & Hematology Coding Alert

When your practice submits your next ESA claim to Medicare, you could be putting reimbursement at risk if you haven't combed through Medicare's latest reporting policy. Good news: We-ve done the work for you and analyzed what you need to know.

The lowdown: Beginning Jan. 1, 2008, if any of your patients are receiving services involving Part B anti-anemia drugs -- other than erythropoiesis stimulating agents (ESAs) used in cancer treatment that are not self-administered -- or ESA administrations, you-ll need to report their most recent hemoglobin (HGB) or hematocrit (HCT) levels, according to CR5699.

What this means to you: Before you submit a claim, be sure your clinical staff has documented these levels in the patient's chart so you can include it on the claim. But that's not all. Follow these tips to keep your claims on the up and up.

"The national coverage determination is very hard to interpret -- one minute you think you have the policy down pat, and the next minute you-ll be scratching your head. There are issues because the NCD is not straightforward, and there are too many loopholes in the policy without clear explanation," says Kelly Reibman, CPC, a biller with oncologist Mariette Austin, PhD, MD, in Bethlehem, Pa.

One potential issue that could cause some confusion for coders is the difference between CR5699's Jan. 1 effective date and the implementation date (April 7), Reibman says.

Effective date means the date the guideline/coding change becomes effective, and implementation date means the date it will be applied, such as by carriers, says Catherine Brink, CMM, CPC, CMSCS, president of Healthcare Resource Management in Spring Lake, N.J.

Potential problem: If the dates indicate that all claims for services on or after Jan. 1, 2008, have to meet all requirements but that contractors won't be required to process these services until April 7, 2008, this could create a three-month lag in reimbursement.

In addition to watching HGB and HCT levels, there are several HCPCS codes you-ll need to keep in mind for reporting ESA injections:

- J0881 -- Injection, darbepoetin alfa, 1 mcg (non- ESRD use)

- J0882 -- Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)

- J0885 -- Injection, epoetin alfa (for non-ESRD use), 1000 units

- J0886 -- Injection, epoetin alfa, 1000 units (for ESRD on dialysis)

- Q4081 -- Injection, epoetin alfa, 100 units (for ESRD on dialysis).

Although you should be familiar with all the codes from this list, the codes you-ll need to focus on primarily for oncology and hematology are non-ESRD codes J0881 and J0885.

When you use J0881 and J0885, you need to remember that you now have to include one -- and only one -- of three new HCPCS modifiers on any non-ESRD claims for the administration of ESAs. These modifiers also became effective Jan. 1, 2008, and need to appear on the same line as the ESA HCPCS code. The new modifiers are:

- EA -- ESA administered to treat anemia due to anticancer chemotherapy

- EB -- ESA administered to treat anemia due to anticancer radiotherapy

- EC -- ESA administered to treat anemia not due to anticancer radiotherapy or anticancer chemotherapy.

For example: If under an oncologist's supervision your nurse injects a patient with Aranesp for chemotherapy-caused anemia, you should report J0881-EA. And be sure to watch your units -- only report one unit per mcg administered.

Remember, J0881 describes the supply of the drug, so you should report the administration code separately, such as 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). You also need to report an accurate diagnosis code such as 284.89 (Other specified aplastic anemias), which describes aplastic anemia due to chronic system disease, drugs, infection or radiation.

You should use an additional E code to identify the cause. In this case, for chemotherapy-associated anemia, report E933.1 (Primarily systemic agents; antineoplastic and immunosuppressive drugs). Some payers may require you to also include the neoplasm diagnosis.

You can only report one of the new modifiers (EA, EB or EC). If you fail to use a modifier when you submit for reimbursement, the payer will deny the claim, says Janae Ballard, CPC, CPC-H, CPC-E/M, ACS-EM, revenue coding analyst for Virginia Mason Medical Center in Seattle.

More pitfalls: "If the incorrect modifier is attached and doesn't match the diagnosis -- for example, attaching modifier EA, but billing with 585.3 (Chronic kidney disease, Stage III [moderate]) and 285.21 (Anemia in chronic kidney disease) -- the claim will be denied," Ballard says.

"Also, if modifier EB is used, the claim will be automatically denied because anemia secondary to radiotherapy is not medically necessary," Ballard says.

The payer will also return your claim as unprocessed if you report more than one of the modifiers.

Reibman says that CR5699 had a significant impact on reimbursement for her practice. "We haven't administered ESA since November 2007," she says. "We recently started giving ESAs to Medicare patients who have low HGB or who have received three or more transfusions."

Despite this, Reibman says that you can take steps to keep mandatory HGB- or HCT-level reporting from causing too many headaches. One simple solution is coordination between the coders and the nursing and medical assistance staffs. "For example, the nurse and/or medical assistant can write the HGB or HCT and the date on the encounter forms for the coders to submit,"

Reibman says.

For more info: You can find out more information on the specifics of CR5699, "Reporting of Hematocrit or Hemoglobin Levels on All Claims for the Administration of Erythropoiesis Stimulating Agents (ESAs), Implementation of New Modifiers for Non-ESRD ESA Indications, and Reporting of Hematocrit or Hemoglobin Levels on all Non-ESRD, Non-ESA Claims Requesting Payment for Anti-Anemia Drugs," on the CMS Web site at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5699.pdf.