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coding for the J0885 (Epogen, Procrit)

  1. #1
    Default coding for the J0885 (Epogen, Procrit)
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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

  2. #2
    Default
    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.

  3. #3
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    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!!
    Jessica B, CPC, CPMA, CANPC

  4. #4
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    I regreted to inform you that these are medicare patients, and medicare does allow v codes for primary diag codes. But thank you for your input.

  5. #5
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    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

  6. Default 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

  7. Default
    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

  8. Default
    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

  9. #9
    Location
    Seacoast- Dover New Hampshire
    Posts
    609
    Default
    Are the modifiers only for the HIghmark carrier? I am in NH and we do not have a clinic dedicated to epo/procrit shots.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  10. #10
    Location
    Somers Point New Jersey
    Posts
    53
    Default
    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.

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