Orthopedic Coding Alert

Get your insurer's erythropoeitin policy in writing before you inject If you're administering epoetin alfa (EPO) injections to your arthroplasty patients without preauthorization, you may be forfeiting about $450 per injection. Some insurers still don't cover EPO injections for non-renal disease diagnoses, and most others allow preoperative EPO injections for anemic patients only.
 
Orthopedic surgeons often recommend EPO (also known as erythropoeitin, or by its trade names, Epogen and Procrit) injections for anemic patients who will lose two or more units of blood during joint replacement surgery. No national Medicare EPO reimbursement policy exists, however, leaving local carriers to determine whether payment is allowable - and at $11.62 per 1,000 units, EPO can get very expensive.
 
ome payers, such as Empire Medicare Services, a Part B provider in New Jersey, do not cover preoperative EPO injections (Q0136, Injection, epoetin alpha [for non- ESRD use], per 1,000 units) for non-renal disease patients under any circumstances. Other payers, however, reimburse EPO under very restrictive conditions.
 
"If a physician believes that a surgery may cause major blood loss and the patient is borderline anemic and unable to donate autogenous blood, then sometimes Procrit is covered," says Mary J. Brown, CPC, CMA, orthopedic coding specialist at Ortho-West PC, a seven-physician practice in Omaha, Neb. But don't bet odds that your carrier will always pay, especially considering that the Department of Health and Human Services Office of Inspector General is watching EPO injections this year.
 
"Currently, Procrit for preoperative use is under the scrutiny of the OIG," says Annette Grady, CPC, CPC-H, healthcare consultant at Eide Bailly LLP in Bismarck, N.D. "Therefore, many times carriers are looking for the documentation to support the claim and may initially deny the claim in order to get the appropriate documentation during the appeal process." Don't Precertify - Preauthorize Instead Carriers that allow preoperative EPO injections require that you follow their guidelines to the letter, and these policies can vary greatly. Blue Cross/Blue Shield of
Alabama, for example, covers EPO injections for patients who meet the following requirements:
  Are undergoing elective, noncardiac, nonvascular surgery
  Have an anemia with a hematocrit between 30 and 39 percent
  Are not candidates for autologous blood transfusion
  Are expected to lose more than two units of blood
  Have had a workup indicating that their anemia appears to be that of chronic disease. "I would suggest that the physician write a letter to the insurance company asking for 'preauthorization,' not just precertification," Brown says. "I would give the codes and prices in the letter, and also the reason the physician intends to administer Procrit. I would also add why conventional therapies would not work on the patient (e.g., autogenous blood donation) and would request their Procrit reimbursement rate [...]