Action Alerts

Reporting Hemoglobin or Hematocrit When Billing
Erythropoiesis Stimulating Agent (ESA)
February 2008

Transmittal 1412 dated January 11, 2008 noted that effective January 1, 2008 when requesting payment for the administration of Erythropoiesis Stimulating Agent (ESA), the most recent levels of hemoglobin or hematocrit must be reported along with 1 of 3 designated modifiers on any Medicare claim when the patient receives 1) ESA administration or 2) Part B anti-anemia drugs other than ESA used in the treatment of cancer that are not self-administered.

Section 110 of Division B of the Tax Relief and Health Care Act of 2006 directs the Secretary to amend Section 1842 of the Social Security Act by adding at the end of the following new subsection "(u) Each request for payment, or bill submitted, for a drug furnished to an individual for the treatment of anemia in connection with the treatment of cancer shall include (in a form and manner specified by the Secretary) information on the hemoglobin or hematocrit levels for the individual."

Implementation date for this requirement is April 7, 2008.

Effective January 1, 2008 CMS implemented a reporting requirement for all claims billed with the administration of ESA. All claims for ESA administration also require the reporting of either the most recent hemoglobin or hematocrit reading.

The HCPCS codes involved are: J0881, J0882, J0885, J0886 and Q4081. The hemoglobin reading is reported with a value code 48 and a hematocrit reading is reported with the value code 49. Claims not reporting a value code 48 or 49 will be returned to the provider.

Facilities should bill at a frequency that allows for the most recent hematocrit or hemoglobin reading to the start of the billing period applicable to the administration(s) billed or the claim. This could mean that a provider could have to submit more than one claim for the month if there were multiple readings applicable to the administration given during the month.

In addition, claims with the administration of ESA must also contain one of the following 3 modifiers:

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

ESAs administered for more than one of the indicated therapies are to be billed as separate line items (i.e., ESAs for chemo-induced anemia (EA modifier) are reported as separate line items (e.g. J0881EA); ESAs for radio-induced anemia (EB modifier) are reported as separate line items (e.g., J0885EB); ESAs for non-chemo/radio induced anemia (EC modifier) are reported as separate line items (e.g., J0881EC)). Only one of the three ESA modifiers may be reported at the line item level.

Lastly, effective January 1, 2008, all claims for the administration of Part B anti-anemia drugs OTHER THAN ESAs used in the treatment of cancer that are not self-administered shall require reporting of either the most recent hematocrit or hemoglobin reading.

Failure to report this information will result in your claim being returned as unprocessed.

In order to meet the elements of this billing requirement, several departments must be involved. For example, the physician must document whether the patient's anemia is chemo-induced or radio-induced or non-chemo/radio induced. Pharmacy will be dispensing the drug, yet they could be unaware of the reason why the drug is being ordered by the physician. The most recent hemoglobin or hematocrit readings applicable to the ESA administration must be obtained and reported on the claim. All of these factors will take a coordination of staff and hospital departments to get the bill processed. Is your facility prepared?