Billing and Coding: Erythropoiesis Stimulating Agents
A58982
Medicare requires specific HCPCS codes and single ESA-purpose (EA/EB/EC) and route (JA/JB/JE) modifiers for erythropoiesis-stimulating agent claims, with strict documentation of recent hemoglobin/hematocrit, blood pressure, weight, assessment of other causes of anemia, and clinician signature. ESAs for ESRD patients on dialysis are covered under the ESRD composite rate (use D63.1 and N18.6 and bill the ESRD facility), and non-ESRD ESA use for chemotherapy-induced anemia is allowed only when Hb < 10.0 g/dL or HCT < 30.0%; multiple specified clinical conditions and scenarios (including uncontrolled hypertension, untreated nutritional deficiencies, hemolysis, certain cancer-related anemias, prophylactic uses, and lack of evaluation) will result in claim denial.
"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 ..."