Wiki coding for the J0885 (Epogen, Procrit)

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krssy70

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Does anybody know what diagnosis will support medical necessity for J0885 (Epogen, Procrit) injection. The diag we are using is 1) V67.2 2) CA diag 3) 285.29. Every claim gets denied for medical necessity. The LCD does not specify any medical necessity diag codes. We have to appeal every patient and then it will pay.

Please help :)
Kristen Richard, CPC
 
If you are coding the V code as your primary, that's probably the reason for the denials. You should have the V code as 2nd or 3rd. Most insurance companies will deny anything with a V code as primary.
 
We've had many of these issues here, and found out there are some additional requirements that need to be met:
1 - Report the most recent hemotocrit and hemoglobin readings available when the ESA is administers. This is required for both ESAs and anti-anemia drugs other than ESA.
2 - All non-ESRD claims billing J0881 and J0885 must report one of the following modifiers on the same line as the ESA HCPCS:
EA - ESA, anemia, chemo induced
EB - ESA, anemia, radio-induced
EC - ESA, anemia non-chemo/radio
3 - Meet medical necessity, and the LCD I found that information at was L27492 from highmark Medicare Services
Hope this helps!!
 
Thank you Jessica, that was very helpful. we are utilizing the modifiers and documenting the Hemocrit/Hemoglobin value codes, but the claims still seem to be denied. I think our issue is the diag, and I downloaded the LCD from Highmark...thank you very much for the info...appreciate it..

Kristen :)
 
J0885

As of January 1, 2008 the trailblazer LCD states that a EA, EB, or EC must be reported on J10885 + the most recent lab values of hemoglogin or hematocrit. Are you giving them that information? If the appropriate modifier is EC there are additional requirements.I would use the anemia code 1st then the additional codes. Hope this Helps.

AMM
 
Some info that I have on it besides the modifiers is this...that the first dx needs to be the reason WHY they have anemia and also link those codes to the injection code as well. Also, if this is given during other chemo services at the same encounter and you are using 96372 as the injection code, it needs a 59 modifier.

JK
 
My understanding is for patient's with chemotherapy induced anemia, code as the following
1) 284.89
2) e933.1 or E933.7
3) cancer code

made sure that the h&h are on the claim along with the modifer EA
 
Are the modifiers only for the HIghmark carrier? I am in NH and we do not have a clinic dedicated to epo/procrit shots.
 
I have same question. We are using EA & EC modifiers with J0885, also we are adding recent Hgb & HCT level.
But Medicaid of Ohio denying J0885 stating invalid / missing / incomplete modifier.
What should we exactly need to do regarding modifiers ? what is the correct format to add Hgb & HCT levels with J0885 claims ?

Anuja, CPC-A.:)
 
First. yes you can use V codes as primary dx when the documentation supports the code, there are some V codes that are secondary only, and there are some that are first-listed only, so you need to check the lists in the guidelines to know which. However when you are administering procrit, the physician needs to state the condition for which the procrit is necessary. Most often this is anemia and usually we used anemia unspecified. In chemo patients, the anemia is mostly due to the chemo drugs as opposed to due to the neoplasm, As of Oct 1 a new code was created for chemo related anemia. So the appropriate code to use for patients receiving procrit is the type of anemia documented by the physician. The new code is:

285.3 Antineoplastic chemotherapy induced anemia
Anemia due to antineoplastic chemotherapy
Excludes: anemia due to drug NEC – code to type of anemia
anemia in neoplastic disease (285.22)
aplastic anemia due to antineoplastic chemotherapy(284.89)
from the guidelines:
Anemia associated with chemotherapy, immunotherapy and radiation therapy:
When the admission/encounter is for management of an anemia associated with chemotherapy, immunotherapy or radiotherapy and the only treatment is for the anemia, the anemia is sequenced first. The appropriate neoplasm code should be assigned as an additional code.
 
J0885

I'm not really sure for Ohio. We are using the EA and adding the levels in a value code method. The proper way to enter them all depends on your computer system. Try calling them to see what they are seeing on the claim. They may not be seeing your levels at all. Then you would have to work with your system administrator to obtain a way to add them on the claim. I hope this helps. Good Luck:)
 
Medicare Denials in Error for J0885

Good Afternoon

We had the same issue here with denials on our J0885 procedures come to find out Medicare denied them in error, Medicare stated that they will be reprocessing all of J0885 that were denied in error for payment.

Hope this helps
Margie
 
for the OP

We are also in Ohio and bill J0885 with anemia primary, cancer secondary per Palmetto guidelines and have no problem with our claims. We are also using the -EA, -EB or -EC modifier as appropriate and reporting the last HCT in Block 19 (or the electronic equivalent). Hope this helps!
 
The modifers are correct at EA and EC...for the H/H, put it this way on the claim.

*09.9 20091029

That should work
 
We have been getting denials for J0881. According to documentation, several of our patients receive it for anemia due to chronic renal insufficiency.
585.9, 285.21 are the codes used and our pharmacy adds the EC or EA. We also make sure the H & H are entered. Has anyone else ran into this? I thought we were following the guidelines. :( Could it be because we are not a dialysis facility, we are a hem/onc hospital outpatient department

When our billing department called the carrier, she spoke to 3 different people and received 3 different answers. There has to be a way for everyone to get on the same page.
 
More confusion on the J0885

Someone please help:

We are receiving denials for the J0885 injection. The patient is receiving the injection at the same encounter of the chemotherapy. The pt has developed the anemia due to the chemotherapy. The Hemocrit/Hemoglobin have been docuemented and the claim is also being billed with the EA modifier. We are a hospital based facility and the chemo and injections are billed by the hospital and on a UB-04. So we cannot link diagnosis to procedures. The diagnosis are billed in the same order for each line item. The reason for the visit is the chemotherapy (V58.11) as we are using this as the prime diag. The second diag we are using is the neoplasm ex(182.0) and finally the third diag we are using is the anemia (285.29). Is this the correct way of billing for this scenerio. Please help :eek:
Thank you in advance,
Kristen Richard, CPC
 
I'm sorry abc....I am not sure what you are saying. Pt is coming into out facility for chemotherapy. Visit is not to address anemia. Why wouldn't you use the V58.11 as the prime diag. I am confused???????
 
We have run into the same thing. Our patients are receiving aranesp for anemia due to chronic renal insufficiency. We code 285.21 and 585.9, submit the hgb and the modifier. The claims are still denied. Appeals have been sent and denied yet again. Some of the patients have received iron, but not all. How can we get reimbursed? And since the medicare carrier stated they were not suppose to be sending out notification letters anymore stating the denials, how are we suppose to know the claims were denied?

Please HELP..
 
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