Erythropoietin Stimulating Agents (ESAs) for the Treatment of Anemia Unrelated to Dialysis Therapy: Rounding Error Revised
States Applicable to Alert: American Samoa, Guam, Hawaii, Nevada, Northern Mariana Islands and California
Background Information: From April 1, 2009, through May 9, 2009, there was an error in the EDI system, which may have caused claims submitted with a Hematocrit (HCT) and/or Hemoglobin (HGB) level, to process incorrectly. The system may have been erroneously rounding the levels to the nearest whole number. Claims with .4 or below were rounded down and claims with .5 or higher were rounded up. If the levels were rounded to high (i.e. if the HBG was rounded to 10.0 or the HCT was rounded to 30.0) then the service may have been denied in error.
Applies To Procedure Code(s):
J0881
J0885
Modifier(s): EA
Remark /Reason Codes:
50 - These are non-covered services because this is not deemed a 'medical necessity' by the payer.
N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.hhs.gov/mcd/search.asp. If you do not have Web access, you can contact the contractor to request a copy of the NCD.
MAC Action: Services brought to our attention by affected providers will be adjusted.
Provider Action:
Previously, you were told these claims could be corrected via a telephone reopening. However, due to the complex nature of these services, the reopening should be requested in writing.
If you feel that you have claims that meet this criteria please request your Reopenings in writing to:
J1 MAC – Palmetto GBA
P.O. Box 1252
Augusta, GA
30903-1252
Date Reported: May 15, 2009
Date Resolved: May 15, 2009