HCPCS Modifier EC

Description
Erythropoetic stimulating agent (ESA) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy.

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 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. 
• Hematocrit and/or hemoglobin levels are required for the administration of ESAs or will be rejected.
• 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 transmittal 1413, Change Request 5818 (PDF)
• 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)
• CMS Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 50 (PDF)