Oncology & Hematology Coding Alert

Question: A patient came to our outpatient clinic with an order to receive Retacrit due to chemotherapy-induced anemia. What is the correct way to bill this to Medicare?

AAPC Forum Subscriber

Answer: The important thing to remember in scenarios like this is to make sure your billing reflects the correct reason for administering the erythropoiesis stimulating agent (ESA). The anemia in this case is caused by the patient’s chemotherapy, not by end stage renal disease (ESRD), which is another known cause of decreased production of, or increased resistance to, erythropoietin, a hormone that enables red blood cell production.

You will do this in two ways. First, you will need to choose the correct HCPCS Level II code for the Retacrit, which means bypassing Q5105 (Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units) for Q5106 (Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units). Then, you will need to append one of the following modifiers to the Q5016 per the Centers for Medicare & Medicaid Services (CMS) article Billing and Coding: Erythropoiesis Stimulating Agents (ESAs) (https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56795):

• EA (Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer chemotherapy)
• EB (Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer radiotherapy)
• EC (Erythropoetic stimulating agent (ESA) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy)

In your particular scenario, EA would be the appropriate modifier for the Q5106.

Don’t forget this administration modifier: CMS also requires a modifier to describe the route in which your provider administers the Retacrit. Again, as the patient is not receiving the ESA for ESRD, you can ignore modifier JE (Administered via dialysate) and choose either JA (Administered intravenously) or JB (Administered subcutaneously) as appropriate.

And remember these codes: Last, CMS requires three ICD-10-CM codes to justify medical necessity for the ESA: D64.81 (Anemia due to antineoplastic chemotherapy), Z79.899 (Other long term (current) drug therapy), “and an additional diagnosis code indicating the condition being treated” per the CMS article.