Modifier Coding Alert

Answer: Since Medicare is denying your claim, you are likely reporting the services for an end-stage renal disease (ESRD) patient who has anemia secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma, or lymphocytic leukemia and whose hemoglobin is 10.0g/dL or more or whose hematocrit is 30 percent or greater. Medicare will deny any claim for ESRD erythropoietin stimulating agent (ESA) services when you attach modifier EA (Erythropoietic stimulating agent [ESA] administered to treat anemia due to anti-cancer chemotherapy) to J0881 (Injection, darbepoetin alfa, 1 microgram [non-ESRD use]) or J0885 (Injection, epoetin alfa, [for non-ESRD use], 1000 units). This modifier should only be used for non-ESRD claims.

 

You will also receive a denial for any claims where you report modifier EB (… due to anti-cancer radiotherapy) on non-ESRD ESA services for J0881 or J0885. There is a MLN Matters article that might prove beneficial to you and can be referenced at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5699.pdf.  

 

Pointer: These types of tests are already part of the care of patients with ESRD so you need to show the carrier why you are billing the service for a non-ESRD patient by appending one of the modifiers to only these codes.

 

There is a long list of diagnoses that you can use with non-ESRD ESA services for J0881 or J0885 with modifier EC (… not due to anti-cancer radiotherapy or anti-cancer chemotherapy) that will cause your claim to be denied. To see the list, take a look at CMS Transmittal 1413 on www.cms.hhs.gov/gransittals/downloads/R1413CP.pdf.