Code This ESA Scenario With Ease
Question: We are treating a Medicare patient with Procrit using J0885. The patient has anemia due to chemotherapy, which is being administered to treat the patient’s hepatitis C. What is the correct way to code this? AAPC Forum Participant Answer: According to >Medicare Local Coverage Determination (LCD) A56795, coding and billing for erythropoiesis stimulating agents (ESAs) such as Procrit very much depends on the patient’s context. For the situation you describe, you’ll apply Group 6 coding per the LCD, as the patient does not have a cancer diagnosis and the anemia is induced by the chemotherapy, not by a condition itself. This means to justify medical necessity for administering the Procrit using J0885 (Injection, epoetin alfa, (for non-ESRD use), 1000 units), you’ll need four total diagnosis codes: Mind the modifiers: Medicare also requires the use of two modifiers to provide the reason why the provider is administering the ESA and the route of the drug’s administration. First, you’ll need to use one of the following to indicate why the patient is receiving the ESA: As the patient is receiving the ESA to treat anemia that is not due to chemotherapy being administered for cancer in this situation, EC would be the correct modifier to explain the drug’s use. Then, depending on the route of administration, you’ll use one of the following: In this case, as the patient is not being treated for a condition such as end stage renal disease, you’ll choose either JA or JB. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
