Oncology & Hematology Coding Alert

Question: One of our readers challenged us to review our December advice again on the proper methods for coding the administration of epoetin-alfa (Q0136), stating that Procrit and Epogen are shots, and to use the chemotherapy infusion codes is incorrect. So, we checked with more of our experts, and asked: What is the proper way to bill for epoetin-alfa if the drug is administered after chemotherapy has been completed?


Answer: Epoetin-alfa, a biologically engineered protein marketed as Epogen and Procrit, is an adjunct to chemotherapy drugs and used to treat chemotherapy-induced anemia. The drug stimulates the bone marrow to make new red blood cells. Anemia is a common problem among chemotherapy patients. The drug also is used for the treatment of anemia in Zidovudine-treated HIV-infected patients.

According to Medicare guidelines, epoetin-alfa is eligible for coverage during the period in which the patient is receiving chemotherapy and up to two months after it is completed. The proper procedure code, according to Palmetto Government Benefits Administrator, a Medicare fiscal intermediary, is HCPCS Q0136.

In addition to using Q0136, the provider must show documentation that proves medical necessity and that the drug was administered for its indicated use. Initial claims can be submitted electronically or via hardcopy under Medicare guidelines. But its wise to provide hard copy documentation for that claim to avoid payment delays. Subsequent claims for the same patient can be submitted electronically because detailed documentation is not required.

When epoetin-alfa is administered along with chemotherapy, the reason for its use is evidenced by the presence of a chemotherapy procedure code (96400-966549) and the use of chemotherapy drugs (J9000-J9999). But when epoetin-alfa is being billed after chemotherapy is completed, there is greater need to show medical necessity. You will need to demonstrate anemia and the reason for illness.

Palmetto sets forth the following guidelines for its Medicare providers:

The initial claim should include diagnostic coding to prove chemotherapy-induced anemia, the primary diagnosis should be coded as ICD-9-CM 285.8 or 285.9, acute posthemorrhagic anemia. A secondary diagnosis code for chemotherapy (V581 encounter or admission of chemotherapy) is also needed. Finally, a tertiary diagnosis code to justify the chemotherapy is required (140.0- 204.91 malignancies).

In addition to the diagnosis codes, Palmetto requires the following documentation for chemotherapy-induced anemia:

1. Patients weight in kilograms;
2. Patients starting dosage; and
3. Date and results of the hematocrit/hemoglobin (Hct/Hgb) within one month prior to initiation of epoetin-alfa therapy.

Subsequent claims should include the following:

1. Add the modifier EJ for subsequent claim (Q0136EJ);

2. Use the proper diagnostic coding - as discussed for the
initial claim;

3. Document patients dosage (DUT column); and

4. Document dates and results of the current Hct/Hgb level.

Editors Note: The answer to this coding question was provided by the Palmetto Government Benefits Administrator and by Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant based in North Augusta, S.C., and the American Academy of Professional Coders 1998 Coder of the Year.