Outpatient Facility Coding Alert

Question: Our hospital outpatient department is seeing an increase in Aranesp^® denials. Any ideas on how to prevent them?

Answer: You’re not alone. At the American Academy of Professional Coders Healthcon meeting in May 2017, Pam Brooks, MHA, COC, PCS, CPC, Coding Manager at Wenworth-Douglass Hospital in Dover, New Hampshire, gave attendees a heads up on these challenge and suggested ways to address them.

HCPCS code J0881 (Aranesp^® [non-ESRD]) is sometimes administered to treat anemia (low red blood cell count) in chemotherapy patients. It’s an erythropoiesis stimulating agent (ESA), which means it stimulates bone marrow to produce more red blood cells. It’s used to reduce the likelihood of a patient needing a blood transfusion. Citing the risk of serious, even life threatening side effects, payers require proof of specific conditions to consider ESA therapy reasonable and necessary as a covered benefit (and therefore reimbursable).

It could be that ICD-10 code D50.9 (Iron deficiency, anemia, unspecified) is being reported as an additional diagnosis, Brooks told attendees. The LCD indicates that iron deficiency anemia must be corrected prior to administration, she noted, so you may need to educate providers about the need for additional clinical documentation.

You might also be missing one of these required modifiers, Brooks added:

• EA, Erythropoetic stimulating agent (ESA) administered to treat anemia due to anticancer chemotherapy
• EB, Erythropoetic stimulating agent (ESA) administered to treat anemia due to anticancer radiotherapy
• EC, Erythropoetic stimulating agent (ESA) administered to treat anemia not due to anticancer radiotherapy or anticancer chemotherapy.

To read relevant instructions from CMS, go to Transmittal 1412 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1412CP.pdf) and the related MLN Matters article (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5699.pdf).

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