Oncology & Hematology Coding Alert

Question: We-re having a dispute in our office regarding how to code EPO for cancer patients with anemia. Was there a change in coverage recently?

Texas Subscriber

 Answer: You should check with your local carrier because some payers have changed their coverage rules recently, only covering DPO (J0881, Injection, darbepoetin alfa, 1 mcg [non-ESRD use]) and EPO (J0885, Injection, epoetin alfa [for non-ESRD use], 1000 units) for cancer patients- anemia resulting from chemotherapy.
 
Example: TrailBlazer's new instructions say that when you report J0881 and J0885 for patients with chemotherapy-related anemia, your primary diagnosis code must be 285.9 (Anemia, unspecified) to report the anemia. Your secondary ICD-9 code must be either:
 
- V58.11 (Encounter for antineoplastic chemotherapy) for patients with non-myeloid malignancy receiving chemotherapy that is causing anemia

OR

 - V67.2 (Follow-up examination; following chemotherapy) for patients treated within the three months prior to EPO or DPO administration for non-myeloid malignancy with chemotherapy that caused anemia.

Trailblazer suggests, but doesn't require, adding the ICD-9 code for the malignancy.
 
Reason for change: The FDA released a warning that these drugs don't help and may harm anemic cancer patients not on chemotherapy, and the drugs aren't approved for this use.

Smart: Check your local payer's rules, and keep an eye out for DPO/EPO coverage changes.
 
Don't forget: You must inform patients when you administer a drug off-label. So if you do give DPO or EPO to anemic cancer patients not undergoing chemo, remember that you need the patient's informed consent.