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Edward Posted Wed 23rd of January, 2013 17:54:54 PM


SuperCoder Answered Wed 23rd of January, 2013 19:38:24 PM

Codes J0881 and J0885 rank among the most frequently-billed codes by oncologists, but these J-codes for erythropoiesis stimulating agents (ESAs) carry a heavy load of very specific reporting requirements and volatile reimbursement rates. To be sure your claims for these frequently reported codes are as clean and accurate as possible, apply the tips below for the following codes:

J0881, Injection, darbepoetin alfa, 1 mcg (non-ESRD use)
J0885, Injection, epoetin alfa (for non-ESRD use), 1000 units. Code J0881 is appropriate to report the supply of Aranesp.
Both codes indicate they are specific to "non-ESRD use." ESRD is short for end stage renal disease. Consequently, these codes are appropriate when the injection is connected to oncologic use.

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:

Solid tumors
Multiple myeloma
Lymphocytic leukemia.
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 J0881and 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.

You should report the test results in item 19 if you use the CMS-1500 paper claim form, MM5699 indicates. If you use electronic claims (837P), follow this direction from MM5699: "Report the hemoglobin or hematocrit readings in Loop 2400 MEA segment. The specifics are MEA01=TR (for test results), MEA02=R1 (for hemoglobin) or R2 (for hematocrit), and MEA03=the test results. The test results should be entered as follows: TR= test results, R1=hemoglobin or R2=hematocrit (a 2-byte alpha-numeric element), and the most recent numeric test result (a 3-byte numeric element [xx.x]). Results exceeding 3-byte numeric elements (10.50) are reported as 10.5."

Example: "If the most recent hemoglobin test results are 10.50, providers should enter: TR/R1/10.5, or, if the most recent hematocrit results are 32.3, providers would enter:TR/R2/32.3," MM5699 explains.

Important: Another key to proper J0881 and 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.

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