LCD Reference Article Billing and Coding Article

Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)

A56795

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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General Information

Source Article ID
N/A
Article ID
A56795
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)
Article Type
Billing and Coding
Original Effective Date
08/01/2019
Revision Effective Date
06/27/2024
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

CMS Pub 100-04 Medicare Claim Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 60.4.2 - Facility Billing Requirements for ESAs

CMS Publication 100-04 Medicare Claims Processing Manual, Chapter 17 - Drugs and Biologicals, Section 80.9 – Required Modifiers for ESAs Administered to Non-ESRD Patients

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 11 - End Stage Renal Disease (ESRD), Section 20.3 – Drugs and Biologicals.

CR 11244: Discontinuing the Erythropoietin Stimulating Agent (ESA) Monitoring Policy System Edits under the End Stage Renal Dialysis Prospective Payment System (ESRD PPS). Effective 01/01/2020.

Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L34633.

A number of chronic conditions, especially chronic renal failure, result in decreased production of or relative resistance to erythropoietin, often causing anemia. Supplementation by synthetic drugs with structures identical or similar to naturally occurring erythropoietin has been proven safe and effective in correcting anemia in certain groups of patients.

General Information for Erythropoiesis Stimulating Agents (ESA) claims:

  • No ESA should be given within the context of uncontrolled hypertension.
  • No ESA should be used to replace red blood cell (RBC) transfusions in patients who need immediate urgent correction of anemia.
  • With any ESA, the patient’s medical record should reflect the clinical reason for dose changes and hematocrit (HCT) levels outside the range of 30.0-36.0% (hemoglobin (Hb) levels 10.0-12.0g/dL). Medicare contractors may review medical records to assure appropriate dose reductions are applied and maintained and hematological target ranges are maintained.
  • There may be instances when a patient has a chronic health condition not specifically addressed in this policy for which an ESA is useful treatment. Such scenarios would be expected to demonstrate considerable transfusion dependence and anemia-related symptoms. In the event of denials, an appeals process will allow the opportunity for the provider to substantiate a reasonable and necessary basis for ESA treatment based on medical literature, specialty organization best practice alignment, and the unique clinical circumstances for the beneficiary. Explanatory documentation within the medical record is crucial.

Coding Guidance

For coverage of all drugs and biologicals, such as erythropoiesis stimulating agents (ESAs), used for the treatment of ESRD, please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 11, Section 20.3.

HCPCS Drug Codes:
Healthcare Common Procedure Coding System (HCPCS) codes J0881, J0885, J0888, and Q5106 are for use in patients with non-end stage renal disease (ESRD) conditions.

HCPCS codes J0882, J0887, Q4081, and Q5105 are intended for use only with patients who have ESRD and are on dialysis.

Modifiers:

-EA, EB, EC

Effective January 1, 2008, all non-ESRD claims billing HCPCS Q5106, J0881 and J0885 must begin reporting one of the following modifiers:

  • EA: ESA, anemia, chemo-induced;
  • EB: ESA, anemia, radio-induced;
  • EC: ESA, anemia, non-chemo/radio.

-JA, JB, JE
Route of administration is important information especially with drugs that can be given multiple different ways. All non-ESRD claims reporting HCPCS code J0881, J0885, J0888, or Q5106 and all ESRD claims reporting J0882, J0887, Q4081, and Q5105 must also be reported with 1 and only 1 of the following modifiers:

  • JA-Administered intravenously
  • JB-Administered subcutaneously
  • JE-Administered via dialysate

Claims Reporting-Hemoglobin/Hematocrit

Claims billing for the administration of an ESA (HCPCS codes J0881, J0882, J0885, J0887, J0888, Q4081, Q5105 and Q5106) must report the most recent HCT or Hb reading. Claims not reporting this information will be returned to the provider.

For institutional claims the Hb reading is reported with a value code 48 and a HCT reading is reported with the value code 49.

For professional paper claims, test results are reported in item 19 of the Form CMS-1500 claim form. For electronic claims (837P), providers report the Hb or Hct readings in Loop 2400 MEA segment. The specifics are mEA01=TR (for test results), MEA02=R1 (for Hb) orR2 (for HCT), and MEA03= the test results.

Documentation Requirements

The medical record documentation for patients receiving ESA therapy must support the reasonable and necessary basis for such therapy.

  • All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  • Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  • The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  • For any ESA, the medical record must reflect that ESA therapy for the individualized patient is reasonable and necessary. The medical record must document the most recent blood pressure and demonstrate reasonable control not in significant excess of a baseline range for a given patient, weight in kilograms, date and results of HCT or Hb level prior to the administration of ESA therapy, evidence of assessment ruling out other causative factors of anemia or, if causative factors are present, that they have been managed and that it is still necessary to initiate ESA The dosage and route of administration must be documented.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

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N/A

CPT/HCPCS Modifiers

Group 1

(6 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
EA ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUE TO ANTI-CANCER CHEMOTHERAPY
EB ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUE TO ANTI-CANCER RADIOTHERAPY
EC ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA NOT DUE TO ANTI-CANCER RADIOTHERAPY OR ANTI-CANCER CHEMOTHERAPY
JA ADMINISTERED INTRAVENOUSLY
JB ADMINISTERED SUBCUTANEOUSLY
JE ADMINISTERED VIA DIALYSATE
N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(2 Codes)
Group 1 Paragraph

A. End Stage Renal Disease (ESRD) ON dialysis J0882, J0887, Q4081, and Q5105.
Requires both diagnoses below:

Group 1 Codes
Code Description
D63.1 Anemia in chronic kidney disease
N18.6 End stage renal disease

Group 2

(1 Code)
Group 2 Paragraph

B. Chronic Kidney Disease NOT on dialysis
DUAL DIAGNOSIS NECESSARY FOR J0881, J0885, J0888, and Q5106.
Requires:

Group 2 Codes
Code Description
D63.1 Anemia in chronic kidney disease

Group 3

(11 Codes)
Group 3 Paragraph

AND one of the following:

Group 3 Codes
Code Description
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
N18.30 Chronic kidney disease, stage 3 unspecified
N18.31 Chronic kidney disease, stage 3a
N18.32 Chronic kidney disease, stage 3b
N18.4 Chronic kidney disease, stage 4 (severe)
N18.5 Chronic kidney disease, stage 5

Group 4

(1 Code)
Group 4 Paragraph

C. Indications other than Renal Disease
Anemia related to therapy with Zidovudine (AZT)
DUAL DIAGNOSIS NECESSARY FOR J0881, J0885, and Q5106.
Requires one of the following:

Group 4 Codes
Code Description
D61.1 Drug-induced aplastic anemia

Group 5

(2 Codes)
Group 5 Paragraph

AND one of the following:

Group 5 Codes
Code Description
B20 Human immunodeficiency virus [HIV] disease
B97.35 Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere

Group 6

(3 Codes)
Group 6 Paragraph

Anemia associated with chemotherapeutic medications when medically necessary for a non-cancer diagnosis or following stem cell transplantation and associated immunosuppression.

This policy does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) and does not contain specific diagnosis codes related to CMS Publication 100-03 Medicare National Coverage Determinations (NCD) Manual Chapter 1- Coverage Determinations, Part 2 Section 110.21 - Erythropoiesis Stimulating Agents (ESA’s) in Cancer and Related Neoplastic Conditions.

Drug induced anemia indicates the anemia is secondary to chemotherapy properly administered to treat a non-cancer diagnosis such as Hepatitis C treatment with ribravirin and interferon alfa or ribravirin and peginterferon alfa.

THREE DIAGNOSES ARE NECESSARY FOR J0881, J0885, or Q5106

Requires: *D64.81, *Z79.85, *Z79.899, AND an additional diagnosis code INDICATING THE CONDITION BEING TREATED

Group 6 Codes
Code Description
D64.81 Anemia due to antineoplastic chemotherapy
Z79.85 Long-term (current) use of injectable non-insulin antidiabetic drugs
Z79.899 Other long term (current) drug therapy

Group 7

(16 Codes)
Group 7 Paragraph

Myelodysplastic Syndromes (MDS) for J0881, J0885, or Q5106
Requires:

Group 7 Codes
Code Description
C93.10 Chronic myelomonocytic leukemia not having achieved remission
C93.11 Chronic myelomonocytic leukemia, in remission
C94.6 Myelodysplastic disease, not elsewhere classified
D46.0 Refractory anemia without ring sideroblasts, so stated
D46.1 Refractory anemia with ring sideroblasts
D46.20 Refractory anemia with excess of blasts, unspecified
D46.21 Refractory anemia with excess of blasts 1
D46.22 Refractory anemia with excess of blasts 2
D46.A Refractory cytopenia with multilineage dysplasia
D46.B Refractory cytopenia with multilineage dysplasia and ring sideroblasts
D46.C Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality
D46.4 Refractory anemia, unspecified
D46.Z Other myelodysplastic syndromes
D46.9 Myelodysplastic syndrome, unspecified
Z79.85 Long-term (current) use of injectable non-insulin antidiabetic drugs
Z79.899 Other long term (current) drug therapy

Group 8

(1 Code)
Group 8 Paragraph

Anemia of chronic disease
DUAL DIAGNOSIS NECESSARY FOR J0881, J0885 or Q5106
Requires:

Group 8 Codes
Code Description
D63.8 Anemia in other chronic diseases classified elsewhere

Group 9

(278 Codes)
Group 9 Paragraph

AND one of the following:

Group 9 Codes
Code Description
B17.10 Acute hepatitis C without hepatic coma
B17.11 Acute hepatitis C with hepatic coma
B18.2 Chronic viral hepatitis C
B19.20 Unspecified viral hepatitis C without hepatic coma
B19.21 Unspecified viral hepatitis C with hepatic coma
K50.00 Crohn's disease of small intestine without complications
K50.011 Crohn's disease of small intestine with rectal bleeding
K50.012 Crohn's disease of small intestine with intestinal obstruction
K50.013 Crohn's disease of small intestine with fistula
K50.014 Crohn's disease of small intestine with abscess
K50.018 Crohn's disease of small intestine with other complication
K50.10 Crohn's disease of large intestine without complications
K50.111 Crohn's disease of large intestine with rectal bleeding
K50.112 Crohn's disease of large intestine with intestinal obstruction
K50.113 Crohn's disease of large intestine with fistula
K50.114 Crohn's disease of large intestine with abscess
K50.118 Crohn's disease of large intestine with other complication
K50.80 Crohn's disease of both small and large intestine without complications
K50.811 Crohn's disease of both small and large intestine with rectal bleeding
K50.812 Crohn's disease of both small and large intestine with intestinal obstruction
K50.813 Crohn's disease of both small and large intestine with fistula
K50.814 Crohn's disease of both small and large intestine with abscess
K50.818 Crohn's disease of both small and large intestine with other complication
K50.90 Crohn's disease, unspecified, without complications
K50.911 Crohn's disease, unspecified, with rectal bleeding
K50.912 Crohn's disease, unspecified, with intestinal obstruction
K50.913 Crohn's disease, unspecified, with fistula
K50.914 Crohn's disease, unspecified, with abscess
K50.918 Crohn's disease, unspecified, with other complication
K51.00 Ulcerative (chronic) pancolitis without complications
K51.011 Ulcerative (chronic) pancolitis with rectal bleeding
K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction
K51.013 Ulcerative (chronic) pancolitis with fistula
K51.014 Ulcerative (chronic) pancolitis with abscess
K51.018 Ulcerative (chronic) pancolitis with other complication
K51.20 Ulcerative (chronic) proctitis without complications
K51.211 Ulcerative (chronic) proctitis with rectal bleeding
K51.212 Ulcerative (chronic) proctitis with intestinal obstruction
K51.213 Ulcerative (chronic) proctitis with fistula
K51.214 Ulcerative (chronic) proctitis with abscess
K51.218 Ulcerative (chronic) proctitis with other complication
K51.30 Ulcerative (chronic) rectosigmoiditis without complications
K51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding
K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction
K51.313 Ulcerative (chronic) rectosigmoiditis with fistula
K51.314 Ulcerative (chronic) rectosigmoiditis with abscess
K51.318 Ulcerative (chronic) rectosigmoiditis with other complication
K51.40 Inflammatory polyps of colon without complications
K51.411 Inflammatory polyps of colon with rectal bleeding
K51.412 Inflammatory polyps of colon with intestinal obstruction
K51.413 Inflammatory polyps of colon with fistula
K51.414 Inflammatory polyps of colon with abscess
K51.418 Inflammatory polyps of colon with other complication
K51.50 Left sided colitis without complications
K51.511 Left sided colitis with rectal bleeding
K51.512 Left sided colitis with intestinal obstruction
K51.513 Left sided colitis with fistula
K51.514 Left sided colitis with abscess
K51.518 Left sided colitis with other complication
K51.80 Other ulcerative colitis without complications
K51.811 Other ulcerative colitis with rectal bleeding
K51.812 Other ulcerative colitis with intestinal obstruction
K51.813 Other ulcerative colitis with fistula
K51.814 Other ulcerative colitis with abscess
K51.818 Other ulcerative colitis with other complication
K51.90 Ulcerative colitis, unspecified, without complications
K51.911 Ulcerative colitis, unspecified with rectal bleeding
K51.912 Ulcerative colitis, unspecified with intestinal obstruction
K51.913 Ulcerative colitis, unspecified with fistula
K51.914 Ulcerative colitis, unspecified with abscess
K51.918 Ulcerative colitis, unspecified with other complication
M05.011 Felty's syndrome, right shoulder
M05.012 Felty's syndrome, left shoulder
M05.021 Felty's syndrome, right elbow
M05.022 Felty's syndrome, left elbow
M05.031 Felty's syndrome, right wrist
M05.032 Felty's syndrome, left wrist
M05.041 Felty's syndrome, right hand
M05.042 Felty's syndrome, left hand
M05.051 Felty's syndrome, right hip
M05.052 Felty's syndrome, left hip
M05.061 Felty's syndrome, right knee
M05.062 Felty's syndrome, left knee
M05.071 Felty's syndrome, right ankle and foot
M05.072 Felty's syndrome, left ankle and foot
M05.09 Felty's syndrome, multiple sites
M05.211 Rheumatoid vasculitis with rheumatoid arthritis of right shoulder
M05.212 Rheumatoid vasculitis with rheumatoid arthritis of left shoulder
M05.221 Rheumatoid vasculitis with rheumatoid arthritis of right elbow
M05.222 Rheumatoid vasculitis with rheumatoid arthritis of left elbow
M05.231 Rheumatoid vasculitis with rheumatoid arthritis of right wrist
M05.232 Rheumatoid vasculitis with rheumatoid arthritis of left wrist
M05.241 Rheumatoid vasculitis with rheumatoid arthritis of right hand
M05.242 Rheumatoid vasculitis with rheumatoid arthritis of left hand
M05.251 Rheumatoid vasculitis with rheumatoid arthritis of right hip
M05.252 Rheumatoid vasculitis with rheumatoid arthritis of left hip
M05.261 Rheumatoid vasculitis with rheumatoid arthritis of right knee
M05.262 Rheumatoid vasculitis with rheumatoid arthritis of left knee
M05.271 Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot
M05.272 Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot
M05.29 Rheumatoid vasculitis with rheumatoid arthritis of multiple sites
M05.311 Rheumatoid heart disease with rheumatoid arthritis of right shoulder
M05.312 Rheumatoid heart disease with rheumatoid arthritis of left shoulder
M05.321 Rheumatoid heart disease with rheumatoid arthritis of right elbow
M05.322 Rheumatoid heart disease with rheumatoid arthritis of left elbow
M05.331 Rheumatoid heart disease with rheumatoid arthritis of right wrist
M05.332 Rheumatoid heart disease with rheumatoid arthritis of left wrist
M05.341 Rheumatoid heart disease with rheumatoid arthritis of right hand
M05.342 Rheumatoid heart disease with rheumatoid arthritis of left hand
M05.351 Rheumatoid heart disease with rheumatoid arthritis of right hip
M05.352 Rheumatoid heart disease with rheumatoid arthritis of left hip
M05.361 Rheumatoid heart disease with rheumatoid arthritis of right knee
M05.362 Rheumatoid heart disease with rheumatoid arthritis of left knee
M05.371 Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot
M05.372 Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot
M05.39 Rheumatoid heart disease with rheumatoid arthritis of multiple sites
M05.411 Rheumatoid myopathy with rheumatoid arthritis of right shoulder
M05.412 Rheumatoid myopathy with rheumatoid arthritis of left shoulder
M05.421 Rheumatoid myopathy with rheumatoid arthritis of right elbow
M05.422 Rheumatoid myopathy with rheumatoid arthritis of left elbow
M05.431 Rheumatoid myopathy with rheumatoid arthritis of right wrist
M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist
M05.441 Rheumatoid myopathy with rheumatoid arthritis of right hand
M05.442 Rheumatoid myopathy with rheumatoid arthritis of left hand
M05.451 Rheumatoid myopathy with rheumatoid arthritis of right hip
M05.452 Rheumatoid myopathy with rheumatoid arthritis of left hip
M05.461 Rheumatoid myopathy with rheumatoid arthritis of right knee
M05.462 Rheumatoid myopathy with rheumatoid arthritis of left knee
M05.471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot
M05.472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites
M05.511 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder
M05.512 Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
M05.521 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow
M05.522 Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
M05.531 Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist
M05.532 Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
M05.541 Rheumatoid polyneuropathy with rheumatoid arthritis of right hand
M05.542 Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
M05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip
M05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
M05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
M05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
M05.611 Rheumatoid arthritis of right shoulder with involvement of other organs and systems
M05.612 Rheumatoid arthritis of left shoulder with involvement of other organs and systems
M05.621 Rheumatoid arthritis of right elbow with involvement of other organs and systems
M05.622 Rheumatoid arthritis of left elbow with involvement of other organs and systems
M05.631 Rheumatoid arthritis of right wrist with involvement of other organs and systems
M05.632 Rheumatoid arthritis of left wrist with involvement of other organs and systems
M05.641 Rheumatoid arthritis of right hand with involvement of other organs and systems
M05.642 Rheumatoid arthritis of left hand with involvement of other organs and systems
M05.651 Rheumatoid arthritis of right hip with involvement of other organs and systems
M05.652 Rheumatoid arthritis of left hip with involvement of other organs and systems
M05.661 Rheumatoid arthritis of right knee with involvement of other organs and systems
M05.662 Rheumatoid arthritis of left knee with involvement of other organs and systems
M05.671 Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems
M05.672 Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems
M05.69 Rheumatoid arthritis of multiple sites with involvement of other organs and systems
M05.711 Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement
M05.712 Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement
M05.721 Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement
M05.722 Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement
M05.731 Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement
M05.732 Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement
M05.741 Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement
M05.742 Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement
M05.751 Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement
M05.752 Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement
M05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement
M05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement
M05.771 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement
M05.772 Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement
M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement
M05.7A Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement
M05.811 Other rheumatoid arthritis with rheumatoid factor of right shoulder
M05.812 Other rheumatoid arthritis with rheumatoid factor of left shoulder
M05.821 Other rheumatoid arthritis with rheumatoid factor of right elbow
M05.822 Other rheumatoid arthritis with rheumatoid factor of left elbow
M05.831 Other rheumatoid arthritis with rheumatoid factor of right wrist
M05.832 Other rheumatoid arthritis with rheumatoid factor of left wrist
M05.841 Other rheumatoid arthritis with rheumatoid factor of right hand
M05.842 Other rheumatoid arthritis with rheumatoid factor of left hand
M05.851 Other rheumatoid arthritis with rheumatoid factor of right hip
M05.852 Other rheumatoid arthritis with rheumatoid factor of left hip
M05.861 Other rheumatoid arthritis with rheumatoid factor of right knee
M05.862 Other rheumatoid arthritis with rheumatoid factor of left knee
M05.871 Other rheumatoid arthritis with rheumatoid factor of right ankle and foot
M05.872 Other rheumatoid arthritis with rheumatoid factor of left ankle and foot
M05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sites
M05.8A Other rheumatoid arthritis with rheumatoid factor of other specified site
M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified
M06.00 Rheumatoid arthritis without rheumatoid factor, unspecified site
M06.011 Rheumatoid arthritis without rheumatoid factor, right shoulder
M06.012 Rheumatoid arthritis without rheumatoid factor, left shoulder
M06.021 Rheumatoid arthritis without rheumatoid factor, right elbow
M06.022 Rheumatoid arthritis without rheumatoid factor, left elbow
M06.031 Rheumatoid arthritis without rheumatoid factor, right wrist
M06.032 Rheumatoid arthritis without rheumatoid factor, left wrist
M06.041 Rheumatoid arthritis without rheumatoid factor, right hand
M06.042 Rheumatoid arthritis without rheumatoid factor, left hand
M06.051 Rheumatoid arthritis without rheumatoid factor, right hip
M06.052 Rheumatoid arthritis without rheumatoid factor, left hip
M06.061 Rheumatoid arthritis without rheumatoid factor, right knee
M06.062 Rheumatoid arthritis without rheumatoid factor, left knee
M06.071 Rheumatoid arthritis without rheumatoid factor, right ankle and foot
M06.072 Rheumatoid arthritis without rheumatoid factor, left ankle and foot
M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae
M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites
M06.0A Rheumatoid arthritis without rheumatoid factor, other specified site
M06.1 Adult-onset Still's disease
M06.211 Rheumatoid bursitis, right shoulder
M06.212 Rheumatoid bursitis, left shoulder
M06.221 Rheumatoid bursitis, right elbow
M06.222 Rheumatoid bursitis, left elbow
M06.231 Rheumatoid bursitis, right wrist
M06.232 Rheumatoid bursitis, left wrist
M06.241 Rheumatoid bursitis, right hand
M06.242 Rheumatoid bursitis, left hand
M06.251 Rheumatoid bursitis, right hip
M06.252 Rheumatoid bursitis, left hip
M06.261 Rheumatoid bursitis, right knee
M06.262 Rheumatoid bursitis, left knee
M06.271 Rheumatoid bursitis, right ankle and foot
M06.272 Rheumatoid bursitis, left ankle and foot
M06.28 Rheumatoid bursitis, vertebrae
M06.29 Rheumatoid bursitis, multiple sites
M06.311 Rheumatoid nodule, right shoulder
M06.312 Rheumatoid nodule, left shoulder
M06.321 Rheumatoid nodule, right elbow
M06.322 Rheumatoid nodule, left elbow
M06.331 Rheumatoid nodule, right wrist
M06.332 Rheumatoid nodule, left wrist
M06.341 Rheumatoid nodule, right hand
M06.342 Rheumatoid nodule, left hand
M06.351 Rheumatoid nodule, right hip
M06.352 Rheumatoid nodule, left hip
M06.361 Rheumatoid nodule, right knee
M06.362 Rheumatoid nodule, left knee
M06.371 Rheumatoid nodule, right ankle and foot
M06.372 Rheumatoid nodule, left ankle and foot
M06.38 Rheumatoid nodule, vertebrae
M06.39 Rheumatoid nodule, multiple sites
M06.811 Other specified rheumatoid arthritis, right shoulder
M06.812 Other specified rheumatoid arthritis, left shoulder
M06.821 Other specified rheumatoid arthritis, right elbow
M06.822 Other specified rheumatoid arthritis, left elbow
M06.831 Other specified rheumatoid arthritis, right wrist
M06.832 Other specified rheumatoid arthritis, left wrist
M06.841 Other specified rheumatoid arthritis, right hand
M06.842 Other specified rheumatoid arthritis, left hand
M06.851 Other specified rheumatoid arthritis, right hip
M06.852 Other specified rheumatoid arthritis, left hip
M06.861 Other specified rheumatoid arthritis, right knee
M06.862 Other specified rheumatoid arthritis, left knee
M06.871 Other specified rheumatoid arthritis, right ankle and foot
M06.872 Other specified rheumatoid arthritis, left ankle and foot
M06.88 Other specified rheumatoid arthritis, vertebrae
M06.89 Other specified rheumatoid arthritis, multiple sites
M06.8A Other specified rheumatoid arthritis, other specified site
M32.0 Drug-induced systemic lupus erythematosus
M32.10 Systemic lupus erythematosus, organ or system involvement unspecified
M32.11 Endocarditis in systemic lupus erythematosus
M32.12 Pericarditis in systemic lupus erythematosus
M32.13 Lung involvement in systemic lupus erythematosus
M32.14 Glomerular disease in systemic lupus erythematosus
M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus
M32.19 Other organ or system involvement in systemic lupus erythematosus
M32.8 Other forms of systemic lupus erythematosus
M34.0 Progressive systemic sclerosis
M34.1 CR(E)ST syndrome
M34.2 Systemic sclerosis induced by drug and chemical
M34.81 Systemic sclerosis with lung involvement
M34.82 Systemic sclerosis with myopathy
M34.83 Systemic sclerosis with polyneuropathy
M34.89 Other systemic sclerosis

Group 10

(2 Codes)
Group 10 Paragraph

Prophylactic pre-operative use for reduction of allogeneic blood transfusions prior to elective hip and knee replacement surgery.
BOTH DIAGNOSES ARE NECESSARY FOR J0881, J0885, and Q5106.
Requires:

Group 10 Codes
Code Description
D63.8 Anemia in other chronic diseases classified elsewhere
Z01.818 Encounter for other preprocedural examination

Group 11

(13 Codes)
Group 11 Paragraph

Myelofibrosis for J0881, J0885 and Q5106

Group 11 Codes
Code Description
C94.40 Acute panmyelosis with myelofibrosis not having achieved remission
C94.41 Acute panmyelosis with myelofibrosis, in remission
C94.42 Acute panmyelosis with myelofibrosis, in relapse
D47.1 Chronic myeloproliferative disease
D47.4 Osteomyelofibrosis
D75.81 Myelofibrosis
D75.821 Non-immune heparin-induced thrombocytopenia
D75.822 Immune-mediated heparin-induced thrombocytopenia
D75.828 Other heparin-induced thrombocytopenia syndrome
D75.829 Heparin-induced thrombocytopenia, unspecified
D75.838 Other thrombocytosis
D75.839 Thrombocytosis, unspecified
D75.84 Other platelet-activating anti-PF4 disorders
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description

Please accept the License to see the codes.

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
06/27/2024 R13

Posted 09/26/2024 Under Coding Guidance, Modifiers: JA, JB, JE deleted HCPCS code J0887 from all non-ESRD claims that need to report a route of administration modifier, and added to all ESRD claims.

06/27/2024 R12

Posted 06/27/2024 Under Coding Guidance, Modifiers: JA, JB, JE added HCPCS code J0887 to all non-ESRD claims that need to report a route of administration modifier.

06/01/2023 R11

Posted 06/01/2023 Under CMS National Coverage Policy added CMS IOM Publication 100-02 reference. Under Article Guidance removed all reference to CMD Pub 100-04 Medicare Claim Processing Manual, Chapter 8, Section 60.4.2, and Section 60.4.3.1. Under Article Guidance added bullet points under, General Information for Erythropoiesis Stimulating Agents (ESA) Claims and added information under Coding Guidance, HCPCS Drug Codes, Modifiers EA, EB, EC and JA, JB, JE, Claims Reporting-Hemoglobin/Hematocrit and Documentation Requirements. Removed Contractor Coding Instructions information and Utilization Guidelines references. Under Coding Information CPT/HCPCS Code, Group 3 Paragraph, Group 3 Codes deleted dx code N18.9 from the table. Under Group 4 Paragraph, Group 4 Codes deleted dx codes D64.89 and D75.9 from the table. Under Group 7 Codes added dx code C94.6. Review completed on 4/20/2023.

10/01/2022 R10

Posted 10/27/2022- Under Group 6 Paragraph: added ICD-10 code Z79.85 to the statement Requires: *D64.81, *Z79.85, *Z79.899, AND an additional diagnosis code INDICATING THE CONDITION BEING TREATED.

10/01/2022 R9

Posted 09/29/2022 Under Group 6 and 7 Codes added ICD 10 code Z79.85. Under Group 11 Codes added ICD-10 codes D75.821, D75.822, D75.828, D75.829 and D75.84. These additions were due to Annual ICD-10-CM code updates and are effective 10/01/2022.

10/01/2021 R8

9/30/2021 ICD 10 CM Code annual update-Under Group 11 Codes added D75.838 and D75.839.

07/01/2021 R7

7/01/2021 Under ICD-10 Codes that Support Medical Necessity Group 3 Codes added I12.0, I12.9, I13.0, I13.10, I13.11 and I13.2 ICD-10 Codes that DO NOT Support Medical Necessity Group 1 codes deleted D61.82. Under Bill Type Codes added 012X, 013X, 022X, 023X, 072X and 085X . Under Revenue Codes added 0634, 0635, and 0636. Review completed 5/27/2021

10/01/2020 R6

10/01/2020 ICD-10 CM Code annual update. Group 3 deleted N18.3 and added N18.30, N18.31, and N18.32. Group 9 added: M05.7A, M05.8A, M06.0A, and M06.8A.

02/09/2020 R5

12/26/2019 Content updated related to reconsideration request. ICD-10 Codes that Support Medical Necessity: Added Group 11 Paragraph: Myelofibrosis for J0881, J0885 and Q5106, Group 11 Codes C94.40, C94.41, C94.42, D47.1, D47.4 and D75.81. ICD-10 Codes that DO NOT Support Medical Necessity: Added Group 1 Paragraph: Myelofibrosis for J0881 or J0885 and Q5106 and Group 1 Codes: D61.82. Please see content of LCD updated related to reconsideration request/effective 02/09/2020: Coverage Indications, Limitations, and/or Medical Necessity: Added to Group C: Indications other than Renal Disease, 8. Myelofibrosis. Summary of Evidence, Analysis of Evidence and Bibliography related to reconsideration request included.

01/01/2020 R4

12/19/2019 CPT/HCPCS annual update completed. CPT/HCPCS Codes Group 1 Codes: description change noted to Q5105 and Q5106. Group 8 Paragraph: Anemia of chronic disease added Q5106. Utilization Guidelines added to Article Text. CR 11244: Discontinuing the Erythropoietin Stimulating Agent (ESA) Monitoring Policy System Edits under the End Stage Renal Dialysis Prospective Payment System (ESRD PPS). Removed CMS Pub 100-04 Medicare Claim Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 60.4.1 – ESA Claims Monitoring Policy from National Coverage Policy and referenced content from Article Text. CR 11244: CPT/HCPCS Modifiers: removed ED, EE, and GS modifiers.

11/01/2019 R3

11/01/2019 CMS National Coverage Policy included updates, CPT/HCPCS Modifier table created and associated documents linked. Content has been moved to the new template. No change in coverage.

08/29/2019 R2

9/20/2019 Converted to the new Billing and Coding Article format on 9/11/2019.

08/29/2019 R1

08/29/2019 Group 6 Paragraph added Q5106 to Three diagnoses are necessary for J0881, J0885, or Q5106. Group 7 Paragraph Myelodysplastic Syndromes (MDS) added Q5106.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c11.pdf
Description: CMS Pub 100-02 Medicare Benefit Policy Manual, Chapter 11 – End Stage Renal Disease (ESRD), Section 20.3 – Drugs and Biologicals (Rev. 224, Issued: 06-03-16, Effective: 01-01-16, Implementation: 09-06-16)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c13.pdf
Description: CMS Pub 100-02 Medicare Coverage Policy Manual, Chapter 13 – Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services, Section 120 Services and Supplies Furnished Incident to Physician’s Services (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
Description: CMS Pub 100-02 Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 50.5.2 – Erythropoietin (EPO), (Rev. 1, 10-01-03)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdf
Description: CMS Pub100-04 Medicare Claims Processing Manual, Chapter 8 – Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Sections 10 – General Description of ESRD Payment and Consolidated Billing Requirements (Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdf
Description: CMS Pub 100-04 Medicare Claim Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 60.4 Erythropoietin Stimulating Agents (ESAs) (Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdf
Description: CMS Pub 100-04 Medicare Claim Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 60.4.2 - Facility Billing Requirements for ESAs (Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdf
Description: CMS Pub 100-04 Medicare Claim Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 60.4.4 - Payment Amount for Epoetin Alfa (EPO) (Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdf
Description: CMS Pub 100-04 Medicare Claim Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 60.4.4.1 - Payment for Epoetin Alfa (EPO) in Other Settings. (Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdf
Description: CMS Pub 100-04 Medicare Claim Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 60.4.4.2 - Epoetin Alfa (EPO) Provided in the Hospital Outpatient Department (Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdf
Description: CMS Pub 100-04 Medicare Claim Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 60.4.6.3 Payment amount for Darbepoetin Alfa (Aranesp) (Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdf
Description: CMS Pub 100-04 Medicare Claim Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 60.4.6.4 - Payment for Darbepoetin Alfa (Aranesp) in Other Settings (Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c08.pdf
Description: CMS Pub 100-04 Medicare Claim Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section - 60.4.6.5 - Payment for Darbepoetin Alfa (Aranesp) in the Hospital Outpatient Department (Rev.2582, Issued: 11-02-12, Effective: 04-01-13, Implementation: 04-01-13)
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf
Description: CMS Publication 100-04 Medicare Claims Processing Manual, Chapter 17 - Drugs and Biologicals, Section 80.9 – Required Modifiers for ESAs Administered to Non-ESRD patients
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Other URLs
https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/modifier-esa/
Description: Erythropoiesis Stimulating Agents (ESAs) Modifiers Fact Sheet
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Public Versions
Updated On Effective Dates Status
09/17/2024 06/27/2024 - N/A Currently in Effect You are here
06/18/2024 06/27/2024 - N/A Superseded View
05/23/2023 06/01/2023 - 06/26/2024 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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