If you have questions or comments about the items listed here please email Risë Marie Cleland at: Rise@wsmos.org
CMS Publishes ESA Instructions
The Centers for Medicare & Medicaid Services (CMS) has issued instructions to Medicare contractors and providers for the implementation of the new Erythropoiesis Stimulating Agents (ESA) National Coverage Determination (NCD), the new ESA modifiers and the hematocrit or hemoglobin reporting requirement. The 3 Transmittals are available on the CMS Web site at: www.cms.hhs.gov/transmittals/. Please carefully read each transmittal for the necessary details, the information below is an abbreviated summary of each Transmittal: Transmittal 80 Change Request 5818 Effective July 30, 2007, Implementation date April 7, 2008:
· This CR summarizes the ESA NCD – The ESA NCD is available on the CMS Web site.
Transmittal 1412 Change Request 5699 Effective January 1, 2008, Implementation date April 7, 2008:
· All claims for administration of an ESA - J0881 darbepoetin alfa 1mcg (non-ESRD use), J0882 darbepoetin alfa 1mcg (ESRD on dialysis), J0885 epoetin alfa 1000units (non-ESRD use), J0886 epoetin alfa 1000units (ESRD on dialysis) and Q4081 epoetin alfa 100units (ESRD on dialysis) - must include the most recent hematocrit (hct) or hemoglobin (hgb) test results.
· Non-ESRD claims for administration of an ESA (J0881, J0885) must also include one (only one ESA modifier may be reported per line item) of the following modifiers:
o EA: ESA, anemia chemo-induced
o EB: ESA, anemia radio-induced
o EC: ESA, anemia, non-chemo/radio
· All claims for administration of Part B anti-anemia drugs other than ESAs used in the treatment of cancer that are not self-administered must include the most recent hct or hgb test results. Related article: MLN Matters Number MM5699 Transmittal 1413 Change Request 5818 Effective January 1, 2008, Implementation date April 7, 2008 Instructs Medicare Carriers:
· To deny non-ESRD ESA services for J0881 or J0885 billed with modifier EC when any one of the following diagnosis codes are present:
o 281.2 Any anemia in cancer or cancer treatment patients due to folate deficiency, 281.1, 281.3 B-12 deficiency, 280.0-280.9 iron deficiency, 282.0, 282.2, 282.9, 283.0, 283.2, 283.9-283.10, 283.19 hemolysis, or 280.0, 285.1 bleeding, 205.00-205.21, 205.80-205.91 anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML) or 207.00-207.81 erythroid cancers.
· To deny non-ESRD ESA services for J0881 or J0885 billed with modifier EC for:
o Any anemia in cancer or cancer treatment patients due to bone marrow fibrosis, anemia of cancer not related to cancer treatment, prophylactic use to prevent chemotherapy-induced anemia, prophylactic use to reduce tumor hypoxia, patients with erythropoietin-type resistance due to neutralizing antibodies, and anemia due to cancer treatment if patients have uncontrolled hypertension.
· To deny non-ESRD ESA services of J0881 or J0885 billed with modifier EB.
· To deny non-ESRD ESA services of J0881 or J0885 billed with modifier EA for anemia secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma and lymphocytic leukemia when a hgb 10.0g/dL or greater or hct 30.0% or greater is reported.
Transmittal 1412 instructs Contractors not to retroactively search for claims with dates of service Jan. 1, 2008-April 7, 2008, but they may adjust claims if brought to their attention
Transmittal 1413 also states, “Claims processed prior to April 7, 2008, shall not be searched for adjustment. However, contractors shall adjust claims if brought to their attention.” It is unclear whether these claims could be brought to the contractor’s attention through an audit by the RACs or other contracted auditing agencies. Providers were advised to begin following the ESA NCD since the effective date of July 30, 2007. We have asked Noridian if their system is ready to handle the new ESA modifiers now and will let you know when we hear from them.
