Wiki NCD and non-covered diagnoses for ESA treatment

[wbradhoward]

Checking in to see if anyone can make heads or tails of the 'new' NCD for non-covered diagnoses for Erythropoiesis Stimulating Agents?

I'm referencing: CMS' National Coverage Determination for Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions (110.21)
Medicare Claims Processing Manual, Chapter 17 (drugs and biologicals), paragraph 80.12
MLN Matters Number: MM10318
and CMS Change Request 5818 (found in Transmittal 1413), and Change Request 10138 (found in Transmittal 2005).

While it seems that there are additions to the non-covered diagnosis list, it also appears that these 'changes' just reflect the previously known non-covered diagnoses, and that nothing much is happening here.

Is nothing much happening here? Or is this a big deal for procrit/aranesp use in oncology?

Appreciate any insight,

 

[OncologyOKC]

Hi Brad,
When you look at the very bottom of the NCD online you will see a Revision History. It tells you what was changed and when the changes were made. The last 2 changes to this policy were just revisions to the ICD-10 codes.

Hope this helps.

 

[smithca]

I am glad to see a question regarding ESA's and the new NCD. In reading the new policy from NGS, you can no longer use diagnosis codes D63.1 and N18.3 together. You only can use N18.3, N18.4, N18.5 and N18.6 alone. Per the official guidelines, they need to be reported together but that is not the issue. My question is, the patient is being seen for anemia in CKD, if you no longer can use the D63.1, would you be able to use just the N18.... even though the intent of the visit is for the anemia. We have just started receiving denials from a Medicare managed care company for services rendered in early 2017 which the policy does state it is retro back to 1/1/2017. Any guidance would be appreciated.

 

[wbradhoward]

CMS is 're' reviewing CR 10318

Hey all!

So I was pretty worried when I posted this initially at the end of January. I have since received a response from Pat Brocato-Simmons at CMS. She stated that "CMS is in the process of re-reviewing the coding changes for NCD 110.21. Until this review is complete and CMS makes a final determination, the A/B Medicare Administrative Contractors (MACs) will not implement the edits contained in CR 10318. The A/B MACs will also reprocess any claims that were processed in error from January 1, 2018, that were processed with the additional codes contained in CR 10318 as not payable with the -EC modifier."

This tells me that no change has yet been made, and no claims should currently be denied for having one of the non-covered diagnoses present. That said, I have heard of some Medicare Advantage payers (specifically UHC in Florida) that did deny claims for this reason, citing medical necessity. I have instructed those practices to resubmit the claims; it is my understanding that most practices who have resubmitted these claims have been paid.

I'll make sure to update when/if I hear anything. I had originally drafted a document for my practices that you're free to use or mirror, should you choose. It should be attached to this post.

Good luck to all!