FIRST COAST SERVICE OPTIONS
LOCAL COVERAGE DETERMINATION
CODING GUIDELINES
Contractor’s
Determination Number
J0881
Contractor Name
First Coast Service
Options, Inc.
Contractor
Number
09102 – Florida
09202 – Puerto Rico
09302 – Virgin Islands
LCD Title
Erythropoiesis Stimulating Agents
Coding
Guidelines
J0881 and J0885 are
intended for use for patients who are Non-ESRD and are not yet on dialysis.
J0881 and J0885 are also intended for use with patients who meet the other
indications outlined in the LCD.
J0882 and J0886 are
intended for use only with patients who are ESRD and on dialysis.
Patients with
ESRD receiving administrations of ESAs for the treatment of anemia may receive
intravenous or subcutaneous administrations of the ESAs. Effective for claims
submitted on or after 2/1/2007 with dates of service on or after 1/1/2007, all
providers billing for injections of ESAs for ESRD beneficiaries are encouraged
to include the modifier JA on the claim to indicate an IV administration or
modifier JB to indicate a subcutaneous administration. All providers will be
required to include route of administration modifiers at a future date.
Per Change
Request 5699 the following requirements are effective on 1/1/2008:
Effective
1/1/2008 all claims billing for the administration of an ESA (HCPCS J0881,
J0882, J0885 and J0886) must report the most recent hematocrit or hemoglobin
reading.
Effective
1/1/2008 all non-ESRD claims reporting J0881 or J0885 must begin reporting one
of the following modifiers:
·
EA: ESA, anemia, chemo induced (ICD-9-CM codes identified in list 2 for
J0881 and J0885)
·
EB: ESA anemia, radio-induced
·
EC: ESA anemia, non-chemo/radio (ICD-9-CM codes identified in list 1 for
J0881 and J0885)
Claims that do not report either a Hgb or Hct and one of the three ESA
modifiers will be returned to the provider. ESAs administered for more than one
of the indicated therapies are billed as separate line items. Only one of the
three ESA modifiers may be reported at the line item level.
A complete discussion of the Hgb and Hct Reporting requirements can be
found in CMS manual System, Pub 100-04, Medicare Claims Processing, Chapter 17,
Sections 80.8, 80.9 and 80.10, Change Request 5699, Transmittal 1413, dated
January 11, 2008.
For reporting
requirements related to the National Coverage Decision for ESA use in Cancer
and related conditions, please refer to Change Request 5818, transmittals 80
and 1413. The following is a summary of reporting requirements:
Effective for DOS on or after 1/1/2008, non-ESRD ESA claims that report
the ESA modifier EC (ESA, anemia, non-chemo/radio and one of the following
ICD-9 codes will be denied:
·
Any anemia in cancer or cancer treatment patients due to folate
deficiency 281.2,
·
B-12 deficiency 281.1, 281.3,
·
Iron deficiency 280.0-280.9,
·
hemolysis 282.0, 282.2, 282.9, 283.0, 283.10, 283.19, 283.2, 283.9,
·
bleeding 280.0, 285.1,
·
anemia associated with the treatment of acute and chronic myelogenous
leukemias (CML, AML) 205.00-205.21, 205.80-205.91, and
·
erythroid cancers (207.00-207.81)
*Please note the above are nationally non-covered indications as outlined
in the National Coverage Decision on ESAs in cancer and cancer related
conditions.
Effective for DOS on or after 1/1/2008, non-ESRD ESA claims that report
the ESA modifier EC (ESA, anemia, non-chemo/radio and one of the following
conditions will be denied:
·
Any anemia in cancer or cancer treatments patients due to bone marrow
fibrosis
·
Anemia of cancer not related to cancer treatment
·
Prophylactic use to prevent chemotherapy-induced anemia
·
Prophylactic use to reduce tumor hypoxia
·
Patients with erythropoietin-type resistance due to neutralizing
antibodies
·
Anemia due to cancer treatments if patients have uncontrolled
hypertension
*Please note the above are nationally non-covered indications as outlined
in the National Coverage Decision on ESAs in cancer and cancer related
conditions. Because no specific ICD-9-CM codes exist for the indications listed
out in the above group, this contactor will identify these non-covered
conditions with ICD-9-CM code V49.89 when submitted on claims billing
J0881 or J0885 and the EC modifier. This will indicate that the ESA was given
for a nationally non-covered condition identified in business requirement 5818.1.1
for Change Request 5818.
Effective for DOS on or after 1/1/2008, non-ESRD ESA claims that report
HCPCS J0881 and J0885 billed with ESA modifier EB (ESA, anemia, radio-induced)
will be denied.
Effective for DOS on or after 1/1/2008, non-ESRD ESA claims for HCPCS
J0881 and J0885 billed with modifier EA (ESA, anemia, chemo-induced) for anemia
secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple
myeloma, lymphoma, and lymphocytic leukemia will be denied when the reported
Hemoglobin is > 10.0g/dL or the Hematocrit reported is > 30.0%, whether
the patient is in the initiation phase or maintenance phase of treatment. Also,
ESA treatment duration for each course of chemotherapy includes the 8 weeks
following the final dose of myelosuppressive chemotherapy in a chemotherapy
regime.
A complete discussion of the National Coverage Decision can be found in
CMS Manual System, Pub 100-03, Chapter 1, Section 110.21 and CMS annual System,
Pub 100-04, Medicare Claims Processing Manual, Chapter 17, Section 80.12.The
related Change Request for this NCD is Transmittals 80 and 1412, Change Request
5818, dated January 14, 2008.
All claims not
meeting medical necessity guidelines in this LCD should have the service billed
with modifier -GA or -GZ.
The –GA modifier
should be used when physicians, practitioners, or suppliers want to indicate
that they expect that Medicare will deny a service as not reasonable and
necessary and they do have an ABN signed by the beneficiary on file. A
Medicare Advanced Beneficiary Notice (ABN), Form CMS-R-131, should be signed by
the beneficiary to indicate that he/she accepts responsibility for payment.
The –GZ modifier
should be used when physicians, practitioners, or suppliers want to indicate
that they expect that Medicare will deny an item or service as not reasonable
and necessary and they have not had an Advance Beneficiary Notification
(ABN) signed by the beneficiary.
If the service
is statutorily non-covered, or without benefit category, submit the appropriate
CPT/HCPCS code with the -GY modifier. An ABN should not be used. A waiver such
as the Notice of Exclusions from Medicare Benefits (NEMB) Form CMS-20007 may be
used. The NEMB Form CMS-20007 is available online at
http://www.cms.hhs.gov/medicare/bni/ or http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp.
Chronic Renal
Failure Patients (ESRD on dialysis and ESRD not on dialysis)
For the purpose of
this LCD, the term “not on dialysis” refers to patients that are not on a
regular course of maintenance dialysis. For patients who need occasional
“rescue dialysis”, it would be appropriate to bill J0881 or J0885, since these
patients are not on a regular course of maintenance dialysis.
For patients with
ESRD who are on dialysis, a diagnosis of 285.21 and a diagnosis of 585.6 must
be billed with procedure code J0882 or J0886.
For patients with
ESRD who are not on dialysis, a diagnosis code of 285.21 and a diagnosis
of 403.01, 403.11, 403.91, 404.02, 404.03, 404.12, 404.13, 404.92, 404.93,
585.1, 585.2, 585.3, 585.4, 585.5 or 585.9, must be billed with procedure code
J0881 or J0885. The EC modifier is also required.
Additional
information for J0885:
*285.29 or *285.9 and one of the following must be billed: 042, 070.54,
070.70, V07.8 or 714.0. The EC modifier is also required.
A course of chemotherapy includes the eight (8) weeks following the last
dose of chemotherapy for that course.
Other Comments
N/A
Revision History
|
Date |
Revision |
|
06/30/2009 |
1 - Revision to
update coding requirements for J0881 and J0885. The effective date of this revision is based on date of
service. |
|
02/02/2009 –
Florida |
Original |
Document formatted:
04/17/2009 (SS/st)