Oncology & Hematology Coding Alert

Finding the right diagnosis code for patients who develop anemia due to chemotherapy treatments has never been straightforward -- and now changes in the ICD-9 manual, effective Oct. 1, are catching coders even further off guard. Keep up with cutting-edge changes to anemia coding with this expert advice.

The lowdown: Coding and billing issues become even more complex when your oncologist uses erythropoiesis-stimulating agents (ESAs) like Epogen, Procrit and Aranesp to treat chemotherapy-induced anemia. A recent coverage decision from Medicare may limit oncologists- reimbursement for ESAs. And in 2008, you-ll have to start using a whole new set of modifiers along with your ESA claims.

Coders may have received a shock when they looked in the 2008 ICD-9 manual for a diagnosis for anemia secondary to chemotherapy. Code 284.8 (Other specified aplastic anemias) now appears with an "additional digit required" note -- leaving you to choose between the two codes below it.

What to do: Choose 284.89 (Other specified aplastic anemias), says Millissa Patch, CPC, reimbursement manager at the Cleveland Clinic Taussig Cancer Center. A note beneath that code explains that it describes aplastic anemia due to chronic system disease, drugs, infection or radiation. You should use an additional E code to identify the cause, the manual says. For chemotherapy-associated anemia, report E933.1 (Primarily systemic agents; antineoplastic and immunosuppressive drugs), Patch says. You may also need to include the cancer diagnosis as a third code.

Example: A patient with breast cancer develops aplastic anemia due to her chemotherapy regimen. She presents for treatment of the anemia. Report 284.89 as the primary code. Your secondary codes should include E933.1 and the appropriate neoplasm code from the 174.x range (Malignant neoplasm of female breast).

Report the appropriate 90772-90775 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug] ...) code, along with the HCPCS code for the drug supply -- for example, J0885 (Injection, epoetin alfa [for non-ESRD use], 1000 units) for Epogen.

Watch out: If the chemotherapy is the cause of the anemia, stay away from 285.22 (Anemia of chronic disease; anemia in neoplastic disease). "Code 285.22 is for use for anemia that is due to the malignancy, not for anemia due to antineoplastic chemotherapy drugs," say the ICD-9-CM Official Guidelines for Coding and Reporting, available at http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf.

However, the individual payer policy takes precedence, and it may have more specific coding guidelines to identify covered administrations. Check with your payer for its preferences.

The use of ESAs to treat chemotherapy-related anemia has been attracting more attention since a July 30 national coverage determination (NCD) from the Centers for Medicare & Medicaid Services (CMS). The NCD, "Decision Memo for Erythropoiesis Stimulating Agents for Non-Renal Disease Indications (CAG-00383N)," was itself prompted by a Food & Drug Administration "Black Box" warning on ESAs.

However, CMS- restrictions are "inconsistent with both the FDA-approved labeling and national guidelines," says Joseph S. Bailes, MD, chair of the American Society of Clinical Oncology's (ASCO) government relations council.

Note: For more details on potential coverage limitations, see "Keep Track of Coverage Conditions for ESAs" on page 11.

Concern about ESAs has also led to the creation of some new HCPCS modifiers. Starting in 2008, you-ll start appending these modifiers to help payers track your ESA usage:

- EA -- Erythropoietic stimulating agent (ESA) administered to treat anemia due to anti-cancer chemotherapy

- EB -- Erythropoietic stimulating agent (ESA) administered to treat anemia due to anti-cancer radiotherapy

- EC -- Erythropoietic stimulating agent (ESA) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy

Two additional modifiers will specify hematocrit (Hct) and hemoglobin (Hgb) levels:

- ED -- Hematocrit level has exceeded 39 percent (or hemoglobin level has exceeded 13.0 g/dL) for three or more consecutive billing cycles immediately prior to and including the current cycle

- EE -- Hematocrit level has not exceeded 39 percent (or hemoglobin level has not exceeded 13.0 g/dL) for three or more consecutive billing cycles immediately prior to and including the current cycle.

However: Modifiers ED and EE apply only to end-stage renal disease (ESRD) patients receiving dialysis in renal dialysis facilities, according to Medicare's decision memo, available at http://www.cms.hhs.gov/Transmittals/downloads/R1307CP.pdf.

New requirement: You may also need to start including your patients- Hct and Hgb levels on every chemo-induced anemia claim.

Medicare's final rule for the 2008 fee schedule (CMS-1385-FC) mandates that, starting Jan. 1, 2008, "each request for payment, or bill submitted, for a drug furnished to an individual for the treatment of anemia in connection with the treatment of cancer shall include - information on the hemoglobin and hematocrit levels for the individual."

Some carriers may already require this. United Healthcare (UHC) has had an erythropoietin (EPO) policy in place since July 2007 requiring a recent Hct level (within 30 days) submitted with any claims for Aranesp (J0881-J0882) and Epogen or Procrit (J0885-J0886, Q4081). UHC wants the Hct level in the shaded line of section 24A of the new CMS-1500 form.

Learn more: You can find UHC's policy by searching for "EPO" at http://www.unitedhealthcareonline.com.