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National Government Services, Inc.,
Medical Policy Update – Part A/B Contractors
Revised Local Coverage Determination (LCD) and Supplemental Instructions Article (SIA)
Erythropoietin Stimulating Agents (ESA) LCD
Effective January 1, 2008

 

Erythropoietin Stimulating Agents (ESA) LCD and SIA
R1 Effective Date: January 1, 2008

LCD L25211

R1 (effective January 1, 2008): Language updated to define claim submission, anemia related to chemotherapy.

Typo correction: In March 2007, the FDA issued new warnings against target Hb levels above 12 g/dL (36% Hct) “for all patients.”

The Centers for Medicare & Medicaid Services (CMS) Publication Change Request #5545, July 13, 2007, Implementation of ESRD line item billing for Renal Dialysis Facilities by providing instructions required to submit line item billing EPO on ESRD claims. RDFs will no longer be required to report the value code 68 with the total monthly dosage. The GS modifier will now be reported on the line item(s) that represent an administration of EPO at the reduced dosage.

CMS Publication Change Request #5700, July 20, 2007, Instructions regarding modifiers ED and EE effective January 1, 2008.

Clarification: *For ESA therapy initiated on or after December 1, 2007, National Government Services requires an EPO level less than or equal 100 IU/L.

Added in documentation requirements:
*For patients on ESA therapy for MDS, initiated prior to December 1, 2007, National Government Services requires a physician’s statement that the patient does have MDS be included in the medical record. For ESA therapy initiated on or after December 1, 2007, a copy of the actual bone marrow report must be included in the medical record. MDS cannot be diagnosed definitively until a bone marrow biopsy is performed to confirm the diagnosis.

No additional comment or notice periods required and none given.

SIA (A44399)

Article published January 1, 2008:  Language updated to define claim submission regarding anemia related to chemotherapy.

Typo correction: In March 2007, the FDA issued new warnings against target Hb levels above 12 g/dL (36% Hct) “for all patients.”

CMS Publication Change Request #5545, July 13, 2007, Implementation of ESRD line item billing for Renal Dialysis Facilities by providing instructions required to submit line item billing EPO on ESRD claims. RDFs will no longer be required to report the value code 68 with the total monthly dosage. The GS modifier will now be reported on the line item(s) that represent an administration of EPO at the reduced dosage.

CMS Publication Change Request #5700, July 20, 2007, Instructions regarding modifiers ED and EE effective January 1, 2008.

 

Posted: 12/20/2007
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