Part B Insider (Multispecialty) Coding Alert

Published on Tue Jan 27, 2004 PDF

You have two choices of codes for non-ESRD Aranesp claims

The Centers for Medicare & Medicaid Services flip-flopped on an important new drug code, and the result is confusion for coders.
 
First CMS said that J0880 Injection, darbepoetin alfa, 5 mcg) wouldn't be payable by Medicare after Jan. 1, 2004. Then in late December, CMS changed its tune and said J0880 would remain payable, but only for claims in the physician office.
 
Complicating matters, CMS recognizes two Q codes for darbepoetin alfa, otherwise known as Aranesp. For patients with ESRD receiving Aranesp, you should use new code Q4054. But CMS also recognizes another code for Aranesp for non-ESRD patients, Q0137. You can't bill for J0880 on the same date as either of these Q codes.
 
In addition to the new code covering Aranesp for ESRD patients, CMS also introduced Q4055, for injection of epoetin alfa, 1,000 units, also for ESRD patients.
 
In transmittal 36, dated Dec. 24, 2003, CMS says physicians have the choice of using either Q0137 or J0880 for nondialysis patients receiving Aranesp. The only difference between the descriptors of the codes is that J0880 is for 5 mcg units, and both Q0137 and Q4054 are for 1-mcg units.
 
In fact, oncology and nephrology practices will greatly prefer to use J0880 because of the larger units, says Menlo Park, Calif.-based oncology consultant Bobbi Buell. With Q0137, practices are likelier to have to bill a three-digit number of units. "Some offices still do not have HIPAA-compliant systems that facilitate three digits," she says. And some private payers can't accept three-digit numbers in the "units" space.
 
Check with your local carrier or payers about coverage guidelines for any of the anemia drugs, including Aranesp, PROCRIT and Epogen,  Buell says. Usually, you'll need to include lab results, such as hematocrit or hemoglobin, on the initial claim. You'll also need a primary diagnosis of anemia (285.9 or 285.2x), plus a code for the underlying disease, such as malignant neoplasm or renal failure.
  
Nancy Martin, a certified professional coder with ACT Medical Group in Rockford, Ill., asked her carrier for more guidance on Aranesp billing. The carrier said more clarifications would be coming out from CMS in February but that providers shouldn't have any trouble billing for now.