Oncology & Hematology Coding Alert

CMS released a slew of documents in 2008 explaining billing requirements for non-ESRD ESA treatment. But even so, one crucial element -- covered diagnoses -- requires some detective work.

Simplify your trek through the various documents -- and find out what they-re missing -- with our expert coding guides.

Term tip: Be sure you-ve memorized these two acronyms before you begin:

- ESRD = End Stage Renal Disease

- ESA = Erythropoiesis Stimulating Agent.

You may want to print the following CMS documents or bookmark them on your computer for reference:

1. National Coverage Determination (NCD) for Erythropoiesis Stimulating Agents (ESAs) in Cancer andRelated Neoplastic Conditions (110.21): www.cms.hhs.gov/mcd/search.asp

The NCD lists nationally covered and non-covered indications.

2. CMS Transmittal 1412, Change Request 5699: www.cms.hhs.gov/transmittals/downloads/R1412CP.pdf

MLN Matters article MM5699: www.cms.hhs.gov/MLNMattersArticles/downloads/MM5699.pdf

The two above documents go into detail on reporting hematocrit (HCT) and hemoglobin (HGB) levels and the modifiers required on your claims.

3. CMS Transmittal 1413, Change Request 5818: www.cms.hhs.gov/transmittals/downloads/R1413CP.pdf

CR 5818 updates the Medicare Claims Processing Manual with the section -Claims Processing Rules for ESAs Administered to Cancer Patients for Anti-Anemia Therapy.-

Before you get into the many specifics of non-ESRD ESA reporting, you need to know which HCPCS codes are involved:

- J0881 -- Injection, darbepoetin alfa, 1 mcg (non-ESRD use) (use this code for Aranesp)

- J0885 -- Injection, epoetin alfa (for non-ESRD use), 1000 units (use this code for Epogen/Procrit).

Bonus tip: Remember to report the administration codes as well. -In 2009 the administration code is 96372 [Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular]. Previously it was 90772,- which had the same descriptor, says Joyce Matola, billing manager for The Center for Cancer and Hematologic Disease in New Jersey.

Denial Prevention: Match Modifiers to Cause CMS requires claims for non-ESRD ESAs (J0881 and J0885) to include one of three modifiers, says Matola:

- 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.

-Professional claims that are billed without the required modifiers will be returned,- warned Roberta Buell, MBA, an oncology reimbursement consultant and partner with onPoint Oncology LLC, in her presentation -Laboratory Coding and ESAs- at The Coding Institute's December 2008 Oncology & Hematology Coding & Reimbursement Conference in Orlando.

The NCD describes indications that are and are not covered. And the ESA entry in the Claims Processing Manual tells carriers when to deny your claims. But these resources don't list covered diagnosis codes.

What to do: Check your local coverage determinations (LCDs) for covered diagnoses, Matola advises.

For example, Part B MAC TrailBlazer lists specific diagnoses for J0885 in its LCD, -Erythropoiesis Stimulating Agents (ESA) -- Non-Dialysis.-

For instance: For treatment of non-dialysis-related anemias with EPO, for a patient with symptomatic anemia associated with chemotherapy, TrailBlazer's LCD instructs you to report 285.9 (Anemia, unspecified) as the primary diagnosis.

For the secondary diagnosis, the LCD says to choosebetween V58.11 (Encounter for antineoplastic chemotherapy) and V67.2 (Follow-up examination;following chemotherapy).

You should use V58.11 for -a non-myeloid malignancy actively receiving chemotherapy that is causing the symptomatic anemia.-

Use V67.2 for -chemotherapy received within the previous three months for a non-myeloid malignancy caused symptomatic anemia.-

Tip: TrailBlazer no longer requires an ICD-9 code for the non-myeloid malignancy, but it does recommend that you include that code on the claim.

One can-t-miss feature of the NCD related to modifier EA claims is that the -ESA treatment for the anemia secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia is only reasonable and necessary- under specified conditions, including -The hemoglobin level immediately prior to initiation or maintenance of ESA treatment is <10 g/dL (or the hematocrit is <30%).-

Medicare lists more conditions that boil down to: the levels must remain below 10 and 30 for Medicare to consider continued administration reasonable and necessary.

Claims impact: -Medicare wants the hematocrit or hemoglobin reported on the claim,- Matola says. When billing Procrit, Aranesp, or Epogen, you must include the most recent HCT or HGB level, she says. You can find this requirement spelled out in MLN Matters article MM5699, revised May 16, 2008.

Matola, who is reimbursement chair for the New Jersey Society of Oncology Managers and J12 MAC region contact for COA's Administrators- Network, has heard that this requirement is causing problems for many practices. She notes that giving the following directions to her billing software vendor has helped prevent issues with her electronic Medicare claims. Note: The instruction is taken from page 3 of MM5699:

-Effective for services on or after January 1, 2008, for professional paper claims, test results are reported in item 19 of the Form CMS-1500 claim form. For professional electronic claims (837P) billed to carriers or A/B MACs, providers 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.

-Examples: 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.-

Tip from the field: Coordinate with the clinical team so the needed information is clearly documented and at your fingertips. For example, you can ask the nurse to write the HGB or HCT level and the date on encounter forms. Or you can place a separate form in the chart's -Laboratory- section where the staff tracks HBG and HCT, including test dates and results. This creates a single section that has both current and historical data.

You don't want to miss the Claims Processing Manual's information on modifier EB and EC claims among all the measurement percentage and decimals.

EB: The Manual states that carriers will deny non-ESRD ESA services for J0881 or J0885 billed with modifier EB (radio-induced).

EC: You also should check the Manual to see the specific diagnoses Medicare won't cover for modifier EC claims. These include, but aren't limited to:

- any anemia in cancer or cancer treatment patients due to folate deficiency (281.2)

- anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML) (205.00-205.21, 205.80-205.91)

- erythroid cancers (207.00-207.81).