Oncology & Hematology Coding Alert

Modifiers and test results are among the 'instant denial' triggers for these codes.

Whether you search under medical oncology, hematology, or hematology/oncology, J0881 and J0885 rank first and third on the lists of the top 10 codes reported to th CMS database (2009).

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.

Learn more: These recently available top 10 rankings are listed in a file posted by Frank Cohen, MPA, principal and Senior Analyst for The Frank Cohen Group. Choose the link for "Top 10 procedure codes by frequency for all specialties" at www.frankcohen.com/html/access.html. To see what other codes fall on those lists, see the Table on page 44.

Warm Up With Code and ESA Definitions

The HCPCS codes in focus are as follows:  

• 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.

Code J0885 applies instead to supply of Epogen or Procrit. Keep in mind that the J codes represent only the supply. You should report the ESA administration separately using 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for intramuscular (IM) administration, says Janae Ballard, CPC, CPC-H,  CPMA, CEMC, PCS, FCS, coding manager for The Coding Source, based in Los Angeles.

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.

What ESAs do: ESAs stimulate bone marrow to produce more red blood cells, according to Medicare's National Coverage Determination (NCD) for ESAs in Cancer and Related Neoplastic Conditions. The goal of use is to reduce the likelihood of a patient's need for a blood transfusion. Studies indicate ESA in oncologic uses may be connected to serious, even life-threatening, events. Citing this risk, payers require proof of specific conditions to consider ESA therapy reasonable and necessary as a covered benefit (and therefore reimbursable).

Dig In to Test Result Requirements for Coverage

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
• Lymphoma
• Lymphocytic leukemia.

Term tip: Myelosuppressive means the anticancer chemotherapy suppresses the bone marrow's blood cell and platelet production. According to the NCD, one of the conditions for coverage is that the patient's hemoglobin is less than 10 g/dL or hematocrit is less than 30 percent. The patient must meet that requirement for treatment to be considered reasonable and necessary.

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."

Straight from the source: The NCD is available in CMS's NCD manual (publication 100-3), section 110.21. You'll find the related Transmittal 80, CR 5818, at www.cms.gov/transmittals/downloads/R80NCD.pdf.

Apply HGB/HCT Requirement to Your Claims

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.

Smart moves: Verify that your billing software vendor has the above information. Also, coordinate with the clinical team on how and where to document the test results.

For instance, "having the ancillary staff write the HGB/ HCT on the charge ticket seems to be the best method for communicating the lab results," Ballard says. For clarity, "be sure that staff is consistently using either the HGB or HCT and not switching between" them, she advises. "The format for entering HGB/HCT can be different if [you're] keying outpatient hospital claims, and the charge entry staff need to know which format to use."

Additionally, you can place a separate form in the chart's "Laboratory" section where the staff tracks the levels, including test dates and results. If your practice uses an electronic medical record (EMR), it may have a "lab" section showing all lab results and dates, Ballard says.

"The charge entry staff could use this to find the most recent lab values," as well, she notes.

Benefit: Medicare will process the claim only if it includes the test results. If you don't include the required information, Medicare will return the claim and you'll have to submit a new, corrected claim.

Resource: You can access MLN Matters article MM5699 at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5699.pdf. It is connected to CMS Transmittal 1412, CR 5699, at www.cms.hhs.gov/transmittals/downloads/R1412CP.pdf.

Tackle the ABCs of EA, EB, and EC

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.

Modifier EA: Use this modifier to indicate the ESA is used to treat anemia caused by chemotherapy. Medicare will deny J0881-EA or J0885-EA if hemoglobin is 10.0g/dL or more, or if hematocrit is 30 percent or greater, according to CMS Transmittal 1413, CR 5818, which updates Medicare Claims Processing Manual, section 80.12.

Modifier EB: This modifier applies when the ESA therapy is for radiation-induced anemia. Medicare will not reimburse J0881-EB or J0885-EB, Transmittal 1413 states.

Modifier EC: When non-ESRD ESA treatment is for anemia not secondary to chemotherapy or radiation, modifier EC applies. Transmittal 1413 supplies a long list of diagnoses that will lead to an instant denial when on the same claim as J0881-EC or J0885-EC. For example, if you report a code from 280.x (Iron deficiency anemias) on your modifier EC claim, expect a denial.

Modifiers EA and EC are the two you're most likely to use, notes Ballard. You can find Transmittal 1413 online at www.cms.hhs.gov/transmittals/downloads/R1413CP.pdf. If you want to know which ICD-9 codes support medical necessity, you'll need to check your payer's local coverage determination (LCD). You'll often find instructions to report multiple diagnosis codes, such as a code for the anemia as well as a code for the cause of the anemia.