Orthopedic Coding Alert
Preauthorize Your EPO Injections - or Risk Forfeiting $450 or More
Get your insurer's erythropoeitin policy in writing before you inject If you're administering epoetin alfa (EPO) injections to your arthroplasty patients without preauthorization, you may be forfeiting about $450 per injection. Some insurers still don't cover EPO injections for non-renal disease diagnoses, and most others allow preoperative EPO injections for anemic patients only. Don't Precertify - Preauthorize Instead Carriers that allow preoperative EPO injections require that you follow their guidelines to the letter, and these policies can vary greatly. Blue Cross/Blue Shield of "I would suggest that the physician write a letter to the insurance company asking for 'preauthorization,' not just precertification," Brown says. "I would give the codes and prices in the letter, and also the reason the physician intends to administer Procrit. I would also add why conventional therapies would not work on the patient (e.g., autogenous blood donation) and would request their Procrit reimbursement rate in writing." List Anemia as Primary Diagnosis Carriers that cover preoperative EPO injections usually reimburse it when performed with the following procedures, although some payers may publish more liberal or restrictive listings: You should list anemia as the primary diagnosis code, but most payers won't reimburse for all of the anemia diagnoses. For example, most carriers will deny your claim if your patient has congenital or hereditary anemias. But most payers will reimburse for patients with unspecified anemia (285.9), constitutional aplastic anemia (284.0), other specified aplastic anemias (284.8), sideroblastic anemia (285.0), and other specified anemias (285.8). Report 1 Unit Per 1,000 Administered In the "units" field of your claim form, you should report one unit of Q0136 for every 1,000 units of EPO that the surgeon administers to the patient. If you administer 40,000 units, for example, you should report 40 units of the drug, totaling a charge of $464.80.
Orthopedic surgeons often recommend EPO (also known as erythropoeitin, or by its trade names, Epogen and Procrit) injections for anemic patients who will lose two or more units of blood during joint replacement surgery. No national Medicare EPO reimbursement policy exists, however, leaving local carriers to determine whether payment is allowable - and at $11.62 per 1,000 units, EPO can get very expensive.
ome payers, such as Empire Medicare Services, a Part B provider in New Jersey, do not cover preoperative EPO injections (Q0136, Injection, epoetin alpha [for non- ESRD use], per 1,000 units) for non-renal disease patients under any circumstances. Other payers, however, reimburse EPO under very restrictive conditions.
"If a physician believes that a surgery may cause major blood loss and the patient is borderline anemic and unable to donate autogenous blood, then sometimes Procrit is covered," says Mary J. Brown, CPC, CMA, orthopedic coding specialist at Ortho-West PC, a seven-physician practice in Omaha, Neb. But don't bet odds that your carrier will always pay, especially considering that the Department of Health and Human Services Office of Inspector General is watching EPO injections this year.
"Currently, Procrit for preoperative use is under the scrutiny of the OIG," says Annette Grady, CPC, CPC-H, healthcare consultant at Eide Bailly LLP in Bismarck, N.D. "Therefore, many times carriers are looking for the documentation to support the claim and may initially deny the claim in order to get the appropriate documentation during the appeal process."
Alabama, for example, covers EPO injections for patients who meet the following requirements:
This may vary on an individual payer basis, so be sure your physician documents his patient's specific type of anemia before you request preauthorization.
Your secondary diagnosis should reflect the reason for the surgery. For example, a patient with constitutional aplastic anemia might require a knee replacement due to primary osteoarthritis of the knee (715.16). You would list her diagnoses as 284.0, 715.16.
If you submit a paper claim, send a copy of your chart notes that document the patient's pretreatment hemoglobin levels. If you submit an electronic claim, you should enter the patient's hemoglobin level using three digits and one decimal point, the test date, and how many EPO doses you administered.
Orthopedic Coding Alert
- Preauthorize Your EPO Injections - or Risk Forfeiting $450 or More
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