Lina Posted Thu 15th of December, 2016 10:16:24 AM
Hi we are getting denials on J0885, stating that these codes (D63.1 and N18.3) can't be primary, PLEASE NEED HELP
SuperCoder Answered Fri 16th of December, 2016 01:58:33 AM
- J0885, Injection, epoetin alfa (for non-ESRD use), 1000 units. This code indicate it is specific to "non-ESRD use." ESRD is a short form of end stage renal disease. Consequently, these codes are appropriate when the injection is connected to oncologic use.
- Secondly: Read through the ESA NCD, and you'll find a list of specific conditions that indicate ESA treatment is reasonable and necessary for anemia caused by myelosuppressive anticancer chemotherapy in:
The NCD also describes recommended dosages for beginning treatment, as well as conditions for coverage to continue treatment based upon how the patient's numbers change over time (as this change indicates the efficacy of the treatment course). Additionally, the NCD states, "ESA treatment duration for each course of chemotherapy includes the 8 weeks following the final dose of myelosuppressive chemotherapy in a chemotherapy regimen."
Because of the above conditions, when you report J0885, Medicare requires you to report "the most recent hematocrit [HCT] or hemoglobin [HGB] reading available when the billed ESA dose was administered," according to MLN Matters MM5699.
- Thirdly: Another key to proper J0885 payment is understanding the following modifiers:
EA, Erythropoetic stimulating agent (ESA) administered to treat anemia due to anticancer chemotherapy
EB, Erythropoetic stimulating agent (ESA) administered to treat anemia due to anticancer radiotherapy
EC, Erythropoetic stimulating agent (ESA) administered to treat anemia not due to anticancer radiotherapy or anticancer chemotherapy.
Requirement: All of your non-ESRD ESA claims must include one of the above modifiers on the same line as your ESA HCPCS code.
Also: If you want to know which ICD-10codes support medical necessity, you'll need to check your payer's local coverage determination (LCD).