Orthopedic Coding Alert

All Medicare carriers provide some erythropoetin coverage, but policies vary

Although many orthopedic practices never thought it would happen, Medicare payers have finally expanded epoetin alfa coverage, and all state carriers now reimburse for these injections to anemic joint-replacement patients.
 
The March Orthopedic Coding Alert article "Pre-Authorize Your EPO Injections -- or Risk Forfeiting $450 or More" described the most effective ways to collect epoetin alfa (also known by its trade names, Epogen and Procrit) reimbursement for joint-replacement patients. As states slowly added EPO coverage, New Jersey was the final holdout, says John F. Kouten, global pharmaceutical communications director at Ortho Biotech Products LP, which manufactures Procrit.

Empire Medicare, a Part B carrier in New Jersey, has finally changed its tune, expanding EPO (Q0136, Injection, epoetin alpha, [for non ESRD use], per 1,000 units) coverage to anemic joint-replacement patients effective for dates of service on or after Jan. 1, 2004.

Empire now covers these injections for patients with Hgb levels between 10 and 13 mg/dl who risk losing a lot of blood during their surgery.

Acceptable Diagnosis Codes Vary Widely

Because carriers' EPO reimbursement guidelines vary widely, you should always get your payer's policy in writing before you perform these injections. Although Empire's policy requires practices to report an appropriate anemia code (such as 285.9, Anemia, unspecified) and either V43.64 (Organ or tissue replaced by other means; hip joint) or V43.65 (... knee), not all carriers maintain similar requirements.

Effective Jan. 5, 2004, for example, "Connecticut Medicare requires us to report E878.1 (Surgical operation with implant of artificial internal device) with our total hip or knee replacement claims to support medical necessity of Procrit," says Harriet Serota, director of patient accounts at Connecticut Family Orthopedics PC. "Other carriers may have changed their policies as well, so practices should check their local policies before billing Procrit to Medicare."

Serota also recommends Procrit's reimbursement line at (800) 553-3851 for additional information.