Billing and Coding: Erythropoiesis Stimulating Agents (ESA)

This billing and coding guidance requires that claims for ESA administration (specific HCPCS codes) include a valid ICD-10 diagnosis and the most recent hemoglobin/hematocrit values reported in the prescribed claim fields; route and indication modifiers (EA/EB/EC, JA/JB) are required/encouraged in specified situations. Documentation must support medical necessity (assessment, history, signed notes, Hgb/Hct, iron stores, weight/kg, ESA units/kg, dialysis or CKD/MDS-specific data), Omontys (J0890) is non-covered, and ABN/denial modifiers (GA/GX/GY/GZ) have specific billing and occurrence code requirements.

"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..."

Sign up to see full coverage criteria, indications, and limitations.