Attention all Administrators, Managers, Nurses and Physicians:
Following is an important update from NHIC Medicare via email to the MOASC office Feruary 3, 2004:

"[NHIC] is providing an updated status on allowing Procrit/Aranesp submitted under procedure codes Q0136, Q0137 or J0880 when rendered for anemia in ESRD or renal patients 'not on dialysis':

* For dates of service 1/1/2004 and after these three codes are allowable when ICD-9's 585 and 285.21 are both submitted as the medical condition;

* System editing was updated on January 27, 2004 to allow payment when these two conditions are billed;

* Mass adjustments will be performed to reprocess claims for Q0136, Q0137 or J0880 submitted for dates of service 1/1/2004 thru 1/27/2004 that were denied when 585 / 285.21 were the reported medical conditions;

* Will let you know when the mass adjustment process has been completed;

* Revised article has not been written or issued on the website yet."

The MOASC office will continue to keep you updated on these developments.

Original Published Guidelines by NHIC Medicare- January 8, 2004:

Darbepoetin Alfa (Aranesp) and Epoetin Alfa (Epogen, EPO) - Billing

This notification contains a change in coding instructions for administration of Darbepoetin Alfa (Aranesp) and Epoetin Alfa (Epogen, EPO) for dates of services on and after January 1, 2004.

· CMS has assigned a new HCPCS code Q4055 for EPO and deleted all the current "Q" codes (Q9920 through Q9940) established for ESRD patients on EPO .

· The code Q0137, injection, darbepoetin alfa, 1 mcg (non-ESRD use) will remain active in all non-ESRD settings.

· The code Q0136, injection epoetin alpha, (for non ESRD use), per 1,000 units remains active for use in all non-ESRD settings.

· J0880 will only be billable when administered in a physician's office to non-ESRD patients not on dialysis .

· A new HCPCS code ( Q4054 ) has been established for ESRD Aranesp usage only .

New codes:

Q4054 Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)

Q4055 Injection, epoetin alfa. 1,000 units (for ESRD on dialysis)

For 2004, physicians have the option of using either Q0137 or J0880 to bill for darbepoetin alfa for non-ESRD patients not on dialysis. For ESRD patients on dialysis treated in a physician's office, code Q4054, "injection, darbepoetin alfa, 1 mcg (for ESRD patients)," should continue to be used with the hematocrit included on the claim. (For ANSI 837 transactions, the hematocrit (Hct) value is reported in 2400 MEA03 with a qualifier of R2 in 2400 MEA02.) Claims without this information will be denied due to lack of documentation, as described in CR 2963. Physicians who provide Aranesp for ESRD patients on dialysis must bill using code Q4054.

NOTE : Billing J0880 and Q0137 for non-ESRD use on the same date of service is not allowable. Billing J0880 and Q4054 for ESRD related use on the same date of service is not allowable.

Billing Instructions:

Claims for Q4054 and Q4055 must contain the Hct value. If the value is not submitted on the claim, it will be denial due to lack of documentation.

• Non-EMC billers shall use Item 19 on the CMS-1500 to place the most current Hct value. (i.e., line 1 Hct= actual Hct level)
• EMC billers shall report the most current Hct value in 2400 MEA03 with a qualifier of R2 in 2400 MEA02.
• For ANSI 837 transactions, pre-HIPAA electronic claims, the Hct value is reported in FAO 43.

The number of units administered of epoetin alfa, Q4055, or darbepoetin alfa, Q4054, will be placed in Item 24G Units on the CMS-1500 form.

For California providers: Procedure codes J0880 and Q0137 will be subject to the diagnosis requirements identified in the Local Medical Review Policy entitled: Epoetin Alfa (Procrit ® , Epogen ® , Eprex ® , erythropoietin, EPO) for the Treatment of Anemia Unrelated to Dialysis Therapy, Coverage of Injection

1/8/04 - Posted

1/15/04 - Revised

Reference: CMS Change Request 2963 and 3037; Transmittal 36; Publication 100-20

See the complete transmittal on the CMS website at http://cms.hhs.gov/manuals/pm_trans/R36OTN.pdf