Revenue Cycle Insider

Question: What is the correct way to bill for RETACRIT^® for a patient undergoing erythropoiesis stimulating agent (ESA) therapy to alleviate anemia caused by their chemotherapy?

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Answer: Coding for RETACRIT^® administration is easy if you follow these four steps.

First, you will need to correctly choose between the two different HCPCS Level II codes for RETACRIT^®. As the drug is being administered for a patient who is not diagnosed with end-stage renal disease (ESRD), you should bypass Q5105 (Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units) in favor of Q5106 (Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units).

Then, if you are following Medicare guidelines, you will need to append the correct ESA modifier to Q5016; per the Centers for Medicare & Medicaid Services (CMS) local coverage determination (LCD) article A58982: “Billing and Coding: Erythropoiesis Stimulating Agents [ESAs],” you should choose from the following:

• 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)

In this case, EA is the appropriate modifier for Q5106.

Third, also per Medicare, you will need to add another modifier to describe the route in which your provider administered the RETACRIT^®. Again, as the patient is not receiving the ESA for ESRD, you can ignore modifier JE (Administered via dialysate) and choose either of the following, as appropriate:

• JA (Administered intravenously)
• JB (Administered subcutaneously)

Last, you will need to add the correct ICD-10-CM codes to provide medical necessity for the drug. Per CMS, they are:

• D64.81 (Anemia due to antineoplastic chemotherapy) or D61.810 (Antineoplastic chemotherapy induced pancytopenia) as appropriate)
• One of the Group 3 ICD-10-CM codes noting the patient’s non-myeloid malignancy as listed in LCD article A58982. Per the article, non-myeloid malignancies as listed in Group 3 “are excluded from coverage.”

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC