Oncology & Hematology Coding Alert

Oncology and hematology groups are working to persuade Medicare to continue reimbursing for erythropoiesis stimulating agents (ESAs) to treat chemotherapy-induced anemia -- but your practice may still need to adjust to some new coverage restrictions.

Groups like the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), and the Community Oncology Alliance (COA) are lobbying hard to overturn Medicare's ESA decision (see main story, page 9).

If the national coverage determination (NCD) stands, however, oncologists will not be allowed to bill ESA treatment unless the patient's hemoglobin level is below 10 grams per deciliter (g/dL) or 30 percent hematocrit, and cannot continue the treatment once levels reach 10 g/dL or greater.

A practice can always begin treatment outside these guidelines, but it cannot charge Medicare unless these guidelines are met.

If the NCD stands, Medicare will not cover ESA treatment for:

- anemia in cancer or cancer treatment patients due to folate deficiency, B-12 deficiency, iron deficiency, hemolysis, bleeding, or bone marrow fibrosis

- anemia associated with the treatment of acute and chronic myelogenous leukemias (AML and CML) or erythroid cancers

- anemia of cancer not related to cancer treatment

- any anemia associated only with radiotherapy

- prophylactic use to prevent chemotherapy-induced anemia

- prophylactic use to reduce tumor hypoxia

- patients with erythropoietin-type resistance due to neutralizing antibodies

- anemia due to cancer treatment if patients have uncontrolled hypertension.

Learn more: You can read Medicare's full NCD at http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=203. Follow COA's action at http://www.communityoncology.org/Default.aspx?tabid=81.