Internal Medicine Coding Alert

Patients suffering from anemia due to end-stage renal disease (ESRD), chemotherapy, myelodysplasia, or AZT treatments often are given injections of the drug epoetin alfa (Procrit) to stimulate the bone marrow to make new red blood cells. Getting appropriate reimbursement for these injections can be tricky because Medicare and commercial payers have different policies and coding requirements for this procedure. Coders must be careful to choose the correct HCPCS codes and also must pay attention to carrier-specific requirements for ICD-9 coding.

Medicare has specific HCPCS Q codes for the injections. And HCPCS coding for these injections differs depending on what condition is causing the anemia, explains Karen Boland, RN, manager of coding, compliance and reimbursement for the University of Alabama Health Services Foundation in Birmingham, Ala. It is given for anemia caused by ESRD and that is one set of codes, or anemia due to other causes, such as chemotherapy-induced anemia, and that is another set of codes. Anemia due to other causes is reported with the HCPCS code Q0136 (injection, epoetin alpha, [for non-ESRD use], per 1,000 units).

For patients with ESRD, codes Q9920-Q9940 (injection of EPO, per 1000 units) should be used, says Boland. The last two numbers in that code are the patients hematocrit level. For example, if the patients hematocrit level were 28, you would report code Q9928. Code Q9920 is used to report a hematocrit level of 20 or less; Q9940 is for a patient who has a hematocrit level of 40 or more.

Coverage Requirements

Medicare has specific rules about coverage of epoetin alfa for patients with anemia due to ESRD, notes Boland. The guidelines are very strict as to when you can give it, and when you should stop giving it.

For example, according to the local review policy of Xact Medicare (the carrier for Pennsylvania), injections cannot be given more frequently than three times per week and the patients hematocrit level should be maintained below 36 unless documented symptoms of anemia require maintaining a higher level. For most covered indications, if there is no response after two months of treatment, the drug should be discontinued, and no reimbursement is allowed. Also, providers must submit supporting documentation with the first claim for an epoetin injection, says Boland.

Tip: Check your carriers local medical review policy on epoetin alfa for specific coverage limitations. Some carriers cover more indications for use of the drug. Medicares overall requirements for coverage of epoetin are covered in the Medicare Carriers Manual sections 2049.5B, 2050.5D, and 2050.5H.

According to the Medicare Carriers Manual, section 4273.1 and 4273.2, Claims Review and Adjudication Procedures, the initial claim requires:

an ICD-9 diagnosis that indicates epoetin is medically indicated;

the specific Q code for the injection (see above);

the date of the patient's most recent hematocrit (HCT) or hemoglobin (Hgb) count;

the most recent HCT or Hgb level prior to initiation of EPO therapy;

the date of the most recent HCT or Hgb level prior
to initiation of EPO therapy;

the patients most recent serum creatinine, within the last month, prior to initiation of epoetin alfa therapy;

the date of the most recent serum creatinine prior to initiation of EPO therapy;

the patients weight in kilograms; and

the patients starting dose per kilogram. (The usual starting dose is 50-100 units per kilogram.)

Subsequent claims require only the ICD-9 code, the appropriate Q code (that reports the patients hematocrit level) and an -EJ modifier (subsequent claims for a defined course of therapy) attached to the Q code to indicate to the carrier that the claim is a subsequent claim and supporting documentation has been provided.

Injection Bundled Into MCP

Primary-care physicians who give epoetin alfa injections to ESRD patients cannot report these injections separately if they report codes 90918-90921 (end stage renal disease [ESRD] related servers per full month) and accept a monthly capitated payment (MCP) for ESRD-related services, says Ron Nelson, PA-C, president of Health Services Associates, a practice management consulting firm in Freemont, Mich. Any dialysis-related service or service related to ESRD is included in the MCP and this would include the epoetin alfa injections, says Nelson.

Note: See Get Paid for Supervision of Dialysis Patients, on page 9 of the February 2000 Internal Medicine Coding Alert.

Commercial Payer Strategy

Even if you are able to report the epoetin injection separately, for commercial insurance plans, it is often very difficult to get appropriate reimbursement for epoetin alfa injections because the medication is so expensive, says Nelson. The cost of the medication alone for a months treatment of anemia related to congestive heart failure can reach $1,000 or more. In my experience, either the payers dont cover it, or what they pay is so little that is just not enough to warrant stocking the medication, says Nelson.

He recommends writing the patient a prescription for the medication, having the patient fill the prescription at the pharmacy, then bring it back to the office for administration of the injection. The practice charges the administration fee (90782, therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular), says Nelson.

In many cases, the medication can be covered under the patients outpatient prescription drug benefit and the practice does not bear the cost of the medication, he says. This may even be an appropriate strategy for Medicare patients, he adds. The patient may have co-insurance that will cover prescription drugs.

Coverage of Epoetin Alfa for Preoperative Use

Although epoetin is also indicated for preoperative useto decrease the risk of transfusion during surgerymany payers do not cover the use of epoetin alfa for this indication. Medicare has left this coverage decision up to the regional carriers, but it did issue a memorandum in August 1999 (HCFA Transmittal No. AB 99-59) clarifying that, for certain patients, preoperative epoetin is not a preventive service but treatment of a medical problem.

It has been reported that a number of carriers are currently considering, or already have implemented, noncoverage policies for the preoperative use of Procrit, based upon the premise that this use of Procrit is a preventive service, the memo states. We have identified a target population for whom this use represents the treatment of an illness. This target population consists of those individuals who:

(1) are undergoing hip or knee surgery;
(2) have an anemia with a hemoglobin between 10
and 13 mg/dL;
(3) are not a candidate for autologous blood
transfusion;
(4) are expected to lose more than 2 units of blood; and
(5) have had a workup so that their anemia appears to be that of chronic disease.

The preoperative use of Procrit may be afforded to these individuals when carriers, exercising their discretion, determine that this treatment is reasonable and necessary.

The decision of whether to cover epoetin for this indication is still up to carriers, but if your physicians give these injections for patients who meet the above criteria, it might be worth appealing to your carrier for coverage.