Anemia in Chronic Disease vs. Iron deficiency

Lisarae1970

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As I am sure everyone knows, medical nec. for Epogen/Procrit has been targeted by EVERYONE. I code for an Oncology/Hematology clinic in Washington state. I code my pt's treatment monthly, which has created a very high denial rate for my Epo pt's. Example: A pt received iron sucrose injections for the 1st 2 weeks of the month, and then becomes eligible for Epogen in the 3rd week, once the iron deficiency is under control. I would code this 285.29+238.75+280.9. Because my claim has 285.29 as well as 280.9, treatment will be denied! Any idea how this can be avoided? Then, in the following month, my pt is still receiving Epo, in addition to taking oral iron for maintenance. I am still going to code 285.29+238.75+280.9, due to the oral supplements. Again, denial. Can I remove the 280.9 in the following month, as the pt isn't actually being treated on site for deficiency, or would that be construed as coding for payment? There has got to be a way to maintain the integrity of my coding, maintain compliance with CMS, and get paid appropriatly at the same time.....right? HELP!!!
 

daisy3663

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Since you are not treating the iron deficiency when giving the Procrit, I would take off the 280.9 and just use the 285.29 + 238.75. You only use the dx codes for the drugs that are given. Since the patient is on oral iron meds, there aren't any drugs you are going to be billing the 280.9 for. You could tie the 280.9 to an office visit but not for drugs that the 280.9 isn't being given for, like the Procrit.
 

abc1099

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I agree with taking the 280.9 off when she isn't IDA anymore, however I find it interesting that you are billing 238.75 with 285.29. We are in Michigan and have to bill 238.75 with 285.9 in order to get our claims paid. The only dx we can use with 285.29 are 555.0-555.9 556.0-556.9, 710.0, 714.0 714.2 and 714.2 for Procrit or Aranesp.
 

Lisarae1970

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Thank you! Dropping 280.9 seems logical, and compliant, but I have come up against some resistance to that. ?????? In Washington, 285.9 either by itself, or with a chronic disease will automatically be denied for lack of medical necessity.
 

tonplair@gmail.com

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Have you been using the hemoglobin and hematocrit because in south carolina in order for us to get paid we have to put first the hemoglobin and then the hematocrit with the hgb need to be under 11 to initiate and the modifier need to be ec
 

relong

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We are in J5 and our MAC requires the lab value in the electronic claim, which we had to work with our IT dept to make work. It also requires either the EA or EC modifier.

Good luck!!!! I know how frustrating it can be getting procrit/aranesp paid.
 

Lisarae1970

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Yes, the Hematocrit & Hemoglobin are required values to provide medical nec. These values are monitored, and doses adjusted as appropriate (at my place of employment anyways) by the pharmacy. The values are not required to be on the claim, but must be documented in the record.
Because I personally reviewed the denial audit, and the MR's that applied, I have an understanding of "why" the denials, just can't figure out how to avoid potential denials in the future. Also, I am only 1 of about 25 coders for this facility. Most of the EPO pt's are mine, however, it does occur in other settings throughout our facility. That is a training issue I have no control over, but I guess it is job security for me, as someone will need to review and adjust these denied claims!
 

mitchellde

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If I can ask what has the physcian documented as the type of anemia the patient has. If it is due to chemotherapy then that is different than anemia of chronic illness. I have observed many anemia codes utilized in billing for these drugs and when I look at the documentation it is often totally different. Your codes say the patient has an iron deficient anemia as well as MDS as well as a chronic illness causing yet another anemia. Is this truely how it is documented?
 
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Procrit

You should be looking at your LCDs to determine the appropriate codes to use (for Medicare) in conjunction with the physician's documentation. Are you billing on a CMS-1500 or UB04? You can also go to Procrit's website and they have helpful information related to the state you are in.

Here in Ohio, 238.75 unspecified MDS will not be paid for so we have to determine whether it is high or low. We were getting denials because the order would say "anemia" and the coders would code 285.9 and that was a denial even if we had the hgb value.
In my short time in oncology, Procrit I learned my first week and it all starts with educating the physicians on what and how to document the orders. Even if their notes have chemo induced anemia, that needs to be on the orders also.
I feel your pain. Good luck.
 
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procrit

Once you show why Procrit is getting denied and how much it is costing your facility, they should listen. I did that and the physician's totally understood. I gave the figures to my manager and then put together a presentation of the inconsistencies of the documentation and it has helped
 
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