Description
Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer radiotherapy.

HCPCS Procedure Codes

  • J0881
  • J0885
  • Q5106

Guidelines/Instructions

  • Non-end-stage renal disease (non-ESRD) claims for the administration of erythropoiesis stimulating agents (ESAs) must contain one of the following HCPCS modifiers: EA, EB or EC. Non-ESRD claims for ESAs submitted without one of these modifiers will be rejected with remark codes MA130 and CO-16 and must be corrected and resubmitted.
  • Report only one ESA modifier with each appropriate procedure code. If the ESA is submitted with multiple ESA modifiers, it will be rejected with remark codes MA130 and N63 and reason code CO-16. 
  • Hematocrit and/or hemoglobin levels are required for the administration of ESAs or will be rejected with remark codes MA130 and N764 and reason code CO-16
  • For electronic claims, report the most recent hematocrit or hemoglobin level in Loop 2400 MEA segment. Specifically: MEA01=TR (for test results), MEA02=R1 (for hemoglobin) or R2 (for hematocrit), and MEA03=the test results. Enter the test results as follows: TR=test results, R1=hemoglobin or R2=hematocrit (a two position alpha-numeric element), and the most recent numeric test result (a three position numeric element [xx.x]).
  • For paper claims, report the most recent hematocrit or hemoglobin level in Item 19 of the CMS-1500 claim form

References

  • CMS MLN Matters article MM5699 (PDF, 74 KB): Reporting of Hematocrit or Hemoglobin Levels on All Claims for the Administration of Erythropoiesis Stimulating Agents (ESAs), Implementation of New Modifiers for Non-ESRD ESA Indications, and Reporting of Hematocrit or Hemoglobin Levels on all Non-ESRD, Non-ESA Claims Requesting Payment for Anti-Anemia Drugs
  • CMS transmittal 1413, Change Request 5818 (PDF, 209 KB)
  • CMS National Coverage Determination 110.21 - for Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
  • CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 17, Section 80.8-80.12 (PDF, 495 KB) 
  • CMS Medicare Benefit Policy Manual (Pub. 100.02), Chapter, Section 50

 

 

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