J0888, Injection, epoetin beta, 1 microgram, (for non esrd use)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.
- Medical record must include most recent blood pressure and demonstrate reasonable control, weight in kilograms, date and results of Hb or HCT prior to ESA administration, and assessment that other causes of anemia are ruled out or managed.
- Every page of the medical record must be legible with patient identification, dates of service, and the legible signature of the responsible physician or non-physician practitioner; submitted records must support the selected ICD-10-CM and CPT/HCPCS codes.
- Non-ESRD claims for J0881, J0885 and Q5106 must include one of modifiers EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio); all applicable ESA claims must report exactly one route modifier: JA (IV), JB (subcutaneous), or JE (via dialysate).
- Claims must report the most recent Hb or Hct reading on the claim: institutional claims use value code 48 (Hb) or 49 (HCT); professional paper claims place results in item 19 of CMS-1500; electronic 837P claims use Loop 2400 MEA with MEA01=TR, MEA02=R1 (Hb) or R2 (HCT), and MEA03=the test result.
- Claims for ESA administration must include the most recent hemoglobin or hematocrit value on the claim (institutional value codes 48 for Hb / 49 for HCT; professional Form CMS-1500 item 19; electronic 837P Loop 2400 MEA segment).
Key Coverage Criteria
- ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
- ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
- ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.
- ESAs are appropriate to treat symptomatic anemia of chronic kidney disease in patients on dialysis when billed using ESRD-specific HCPCS codes (J0882, J0887, Q4081, Q5105) and documented diagnoses D63.1 and N18.6.
- Non-ESRD ESA therapy for anemia due to myelosuppressive anticancer chemotherapy is indicated when billed with HCPCS codes J0881, J0885, J0888 or Q5106 with modifier EA and when the most recent hemoglobin is < 10.0 g/dL or hematocrit is < 30.0%.
- All ESA administrations (ESRD and non-ESRD) must be reported with one ESA-purpose modifier (EA, EB, or EC) and one route modifier (JA, JB, or JE) on the claim to be processed rather than returned.
19 Active Policies
A56795, Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)
J5
WPS-L34633, Erythropoiesis Stimulating Agents (ESAs)
J8
PALMETTO-JJ-L39237, Erythropoiesis Stimulating Agents
JJ
NGS-L40333, Erythropoiesis Stimulating Agents
JK
PALMETTO-JM-L39237, Erythropoiesis Stimulating Agents
JM
BCBSIL-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)
BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care
UMR-POL-UMR-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents
SUREST-POL-SUREST-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents
UHC-POL-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents
AETNA-CPB-0195, Erythropoiesis Stimulating Agents
A58982, Billing and Coding: Erythropoiesis Stimulating Agents
AETNA-CPB-0789, Acute Ischemic Stroke Treatments
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