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Non-ESRD ESA Level Reporting

Reimbursement Policy:
Non-ESRD ESA Level Reporting

Effective Date:
March 18, 2019

Purpose:
Provide guidelines for the processing of Epoetin Alfa injection claim lines (for non-ESRD use) to align with the Tax Relief and Health Care Act of 2008. This policy applies to professional and institutional providers.

Scope:
All Products and Lines of Business are included, except:

  • Medigap
  • Horizon NJ Health
  • COB
  • No-Fault
  • BlueCard Home
  • FEP

All Insured and Administrative Services Only (ASO) accounts and Medicare Advantage plans are included.

Definitions:
Modifier EA: ESA, anemia chemo-induced
Modifier EB: ESA, anemia, radio-induced
Modifier EC: anemia, non-chemo/radio

Policy:
In accordance with Centers for Medicare & Medicaid Services (CMS) Change Request (CR) 5699, to be eligible for reimbursement, procedure codes J0881must be billed with Modifiers EA or EC and J0885 must be billed with Modifiers EA, EB or EC.

Services shall not be considered eligible for reimbursement when:

  • Procedure codes J0881 or J0885 are appended with multiple modifiers EA, EB and/or EC
  • Procedure code J0881 appended with modifier EB
  • Procedure codes J0881 or J0884 appended with modifier EC and billed without one of the following diagnoses:

    Anemia in cancer or cancer treatment patients due to folate deficiency
    D52.0, D52.1, D52.8, D52.9

    B-12 Deficiency
    D51.1, D51.2, D51.3, D51.8, D51.9, D53.1

    Iron Deficiency
    D50.0, D50.1, D50.8, D50.9

    Hemolysis
    D55.0, D55.1, D58.0, D58.9, D59.0, D59.1, D59.2, D59 4, D59.5, D59.6, D59.8, D59.9

    Bleeding
    D50.0, D62

    Anemia associated with the treatment of acute and chronic myelogenous leukemia (CML, AML)
    C92.00, C92.01, C92.02, C92.10, C92.11, C92.12, C92.20, C92.21, C92.40, C92.41, C92.42, C92.50, C92.51, C92.52, C92.60, C92.61, C92.62, C92.90, C92.91, C92.A0, C92.A1, C92.A2, C92.Z0, C92.Z1, C92.Z2

    Erythroid cancers
    C94.00, C94.01, C94.02, C94.20, C94.21, C94.22, C94.30, C94.31, C94.80, C94.81, D45

Procedure: Horizon BCBSNJ shall deny procedure codes J0881 or J0885 when not appended with the appropriate modifier, as provided above.

Horizon BCBSNJ shall deny services when:

  • Procedures codes J0811 and/or J0885 are billed with more than one of the following modifiers EA, EB or EC
  • Procedure code J0881 is appended with modifier EB
  • Procedure codes J0881 or J0885 is appended with modifier EC without billing with an appropriate diagnosis code as provided above.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
10/22/2018: Policy approved

Policy123_V1.0_10222018