Oncology & Hematology Coding Alert

Question: When billing for erythropoiesis-stimulating agents (ESA) drugs such as darbepoetin and epoetin, I am required to bill using numerous modifiers on Medicare claims, such as:

• JA/JB/JE for route of administration
• JW/JZ for waste reporting
• EA/EB/EC for anemia indication
• JG for 340b drug
• PO for provider based location

The electronic claim only allows up to four modifiers to be used on the same code, but I can potentially have up to five modifiers for these drugs on the claim. They are all informational modifiers that don’t affect payment. How should I handle this?

AAPC Forum Participant

Answer: For claims submitted on the CMS-1500 form, you can only enter up to four modifiers, as you correctly state. When this happens, you will use modifier 99 (Multiple modifiers) to indicate you are using more modifiers on the same code. These modifiers will then be listed elsewhere on the claim, depending on payer preference.

For example, Noridian DME, the Medicare Administrative Contractor (MAC) for Jurisdiction D, provides this advice for correctly submitting a claim with more than four modifiers on the same code:

• Replace the fourth modifier with modifier 99 in item 24D.
• Add the overflow modifiers in item 19.
• Provide documentation to explain all modifiers used for each code.

Noridian also tells you not to append other modifiers in item 24D (https://med.noridianmedicare.com/web/jddme/topics/ modifiers/99#).