J0885 ESA modifier EA

Partha

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We are receiving clearing house rejection on J0885 (EPO - ESA treatment) for invalid modifier EA from clearing house, asking us to use any other modifier.

Any suggestions!
 

AmandaW

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What diagnosis are you using? I work at an Hematology/Oncology clinic and we do Procrit and Aranesp all the time. Along with EA, we use EC, EJ and JB.
For EA, it has to be anemia due to chemotherapy-we use 285.9 and V58.11 or E933.1. Usually if they are having chemotherapy that day, we will use
V58.11 secondary, if they are not getting chemo that day, we use E933.1 secondary. I don't think it matters which as they are both on the covered Medicare guidelines. The EC is Anemia of chronic disease-285.29, and then code whatever disease.

Hope this helps!? :)
 

mitchellde

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What diagnosis are you using? I work at an Hematology/Oncology clinic and we do Procrit and Aranesp all the time. Along with EA, we use EC, EJ and JB.
For EA, it has to be anemia due to chemotherapy-we use 285.9 and V58.11 or E933.1. Usually if they are having chemotherapy that day, we will use
V58.11 secondary, if they are not getting chemo that day, we use E933.1 secondary. I don't think it matters which as they are both on the covered Medicare guidelines. The EC is Anemia of chronic disease-285.29, and then code whatever disease.

Hope this helps!? :)
Just a note for you on your dx codes ... V58.11 is a first-listed only dx code so you may never use it secondary. If they are there for the purpose of receiving chemo then it must be sequenced first. In the guidelines for anemia caused by chemo they say:
2)
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 followed by code E933.1. The appropriate neoplasm code should be assigned as an additional code.

In the codes for this next year (2010) there is a new code for anemia due to chemo.
 

AmandaW

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mitchellde, I would agree with you that the book says primary only on V58.11
and V58.12, BUT this is one of those cases with the book guidelines verses the payor's guidelines. We follow Medicare's guidelines as these modifiers are only accepted by Medicare and they make the rules about this. They actually want to see the V58.11 secondary in this case. We never have a problem getting J0881 and J0885 paid UNLESS their counts are too high. It's never for the sequencing of the codes nor the usuage of the modifiers. Also, Medicare doesn't want to see the neoplasm codes on EPO drugs.

Unfortuantely, it's apparent that Medicare rules the world-at least the 'healthcare world' that is! :rolleyes:
 

mitchellde

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mitchellde, I would agree with you that the book says primary only on V58.11
and V58.12, BUT this is one of those cases with the book guidelines verses the payor's guidelines. We follow Medicare's guidelines as these modifiers are only accepted by Medicare and they make the rules about this. They actually want to see the V58.11 secondary in this case. We never have a problem getting J0881 and J0885 paid UNLESS their counts are too high. It's never for the sequencing of the codes nor the usuage of the modifiers. Also, Medicare doesn't want to see the neoplasm codes on EPO drugs.

Unfortuantely, it's apparent that Medicare rules the world-at least the 'healthcare world' that is! :rolleyes:
But these are not the books guidelines these are the CDCs guidelines for correct coding and reporting of ICD-9. I think this first paragraph from the guideline set says it all:
These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself. These guidelines are based on the coding and sequencing instructions in Volumes I, II and III of ICD-9-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-9-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA).
So you see it is a HIPPA requirement that the guidelines be followed when assigning dx codes. And in the guidelines it specifies that the V58.1X codes are first-listed only. Medicare may not overide these guidelines.
 
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