Q4081, Injection, epoetin alfa, 100 units (for esrd on dialysis)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Providers must maintain patient weight in kilograms, ESA units administered per kilogram, and medical justification for any ESA doses exceeding usual doses.
- The medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
- For all patients receiving ESAs the medical record must document hemoglobin (Hgb) or hematocrit (Hct) and evidence of adequate iron stores.
- Dialysis patient records must include dialysis schedule and Hgb/Hct immediately prior to the billing period; home dialysis patients additionally must have a care plan, evidence of home monitoring (including records of ESA supplied and doses administered), patient instructions, and patient selection protocol.
- For CKD (non-dialysis) patients documentation must include serum creatinine, creatinine clearance, or estimated GFR.
- For patients with myelodysplastic syndrome (MDS) documentation must include a bone marrow biopsy report (or a physician statement of MDS if ESA therapy was initiated prior to 2007-12-01), date of ESA initiation, and response to therapy (change in Hgb/Hct and transfusion requirements).
Key Coverage Criteria
- Administration of erythropoiesis stimulating agents (ESAs) billed with HCPCS J0881, J0882, J0885, J0886, Q4081, Q5105, or Q5106 for patients with anemia related to ESRD, chronic kidney disease (CKD), chemotherapy, radiation, or myelodysplastic syndrome (MDS), when the use meets the coverage criteria in the applicable LCD.
- Use of ESAs for chemotherapy-induced, radiation-induced, or non-chemo/non-radiation anemia should be identified on non-ESRD claims by reporting modifier EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio).
- ESA administration may qualify as a Home Health service only when the beneficiary is receiving the ESA for a covered indication specified in the LCD.
- 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.
16 Active Policies
CGS-L34356, Erythropoiesis Stimulating Agents (ESA)
J15
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
BCBSNM-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)
A56462, Billing and Coding: Erythropoiesis Stimulating Agents (ESA)
UMR-POL-UMR-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents
SUREST-POL-SUREST-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents
BCBSOK-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)
A58982, Billing and Coding: Erythropoiesis Stimulating Agents
UHC-POL-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents
AETNA-CPB-0789, Acute Ischemic Stroke Treatments
BCBSIL-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)
BCBSMT-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.