MIR-2007-1A, January 2007

LCD and Article Revisions for January 2007  

Aranesp (Darbepoetin Alfa) for ESRD Use – L19140
LCD Revisions:
The title has been corrected to show Aranesp® (darbepoetin alfa) for ESRD Use.

Under the “CMS National Coverage Policy” section, added numbers 27 and 28:

27. Change Request (CR) 5142, dated June 23, 2006 (annual code update). “Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).”
28. Change Request (CR) 5251, dated August 25, 2006. Revisions to the EPO/Aranesp Monitoring Policy.

Under the “ICD-9-CM Diagnosis Codes That Support Medical Necessity” section, added number 5:

5. List the appropriate anemia diagnosis as the primary diagnosis and the etiology of the anemia as the secondary diagnosis.

Also under this section, removed the following:

Both a Category I and Category II diagnosis code are required.

And, removed the Category I and II sections, combining the ICD-9-CM codes into one section.

Article Revisions:
Under the “Coding Guidelines,” added a new paragraph in number 9:

Effective October 01, 2006, the definition of the GS modifier is: “Dosage of EPO or Darbepoetin Alfa has been reduced and maintained in response to hematocrit or hemoglobin level.”

Also, added number 11:

11. For dates of service April 1, 2006 and later, claims for patients that have opted to receive home dialysis under method 1 or 2 and are self-administering the Aranesp in their home, are not required to report the GS modifier and therefore, are not subject to the 25- percent payment reduction as described in Change Request (CR) 4135.

Under the “CMS National Coverage Policy” section, added numbers 25 – 28:

25. Change Request (CR) 4236, dated December 16, 2005. January 2006, “Non-Outpatient Prospective Payment System Outpatient Code Editor (Non-OPPS OCE) Specifications”
26. Change Request (CR) 4238, dated December 16, 2005. January 2006, “Outpatient Prospective Payment System Outpatient Code Editor (OPPS OCE) Specifications”
27. Change Request (CR) 5142, dated June 23, 2006 (annual code update). “Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).”
28. Change Request (CR) 5251, dated August 25, 2006. Revisions to the EPO/Aranesp Monitoring Policy.

Erythropoietin Alfa (EPO) for ESRD Use – L13700
LCD Revisions:
Under the CMS National Coverage Policy: section added numbers 17 - 19:

17. Change Request (CR) 5142, dated June 23, 2006 (annual code update). “Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).”
18. Change Request (CR) 5251, dated August 25, 2006. Revisions to the EPO/Aranesp Monitoring Policy.
19. Change Request (CR) 5216, dated August 25, 2006. Change in HCPCS for Renal Dialysis Facilities and Hospitals Billing for End Stage Renal Disease (ESRD) Related to Epoetin Alfa (EPO), effective January 1, 2007.

This section has also been updated in the related article.

Under the “CPT/HCPCS Codes” section, updated the NOTE from:

Note: See “Coding Guidelines” section in the article for information pertaining to 13X, 85X, 22X, and 23X bill types and the HCPCS code J0886.

To show the following:

Note: See “Coding Guidelines” section in the article for information pertaining to bill types 13X, 85X, 22X, and 23X, the HCPCS code J0886 and revenue code 0636.

Also under this section, removed the HCPCS code J0886 and added the new code Q4081.

Under the “ICD-9-CM Diagnosis Codes That Support Medical Necessity” section, updated number 4 from:

4. One ICD-9-CM diagnosis code from each category must be included on the claim for Medicare coverage.

To show the following:

4. List the appropriate anemia diagnosis as the primary diagnosis and etiology of the anemia as the secondary diagnosis.

Also under this section, removed Category I and Category II sections, and combined the ICD-9-CM codes into one section.

In the “Revision History Explanation” section, added the following information:

September 4, 2006 - This policy was updated by the ICD-9 2006-2007 Annual Update (Descriptor Changes) - ICD-9-CM codes 403.01, 403.11, 403.91, 404.02, 404.03, 404.12, 404.13, 404.92, and 404.93

Article Revisions:
Under the “Coding Guidelines” section, updated number 2 from:

2. The SNF bill type codes 22x and 23x are not acceptable for this service (services performed on or after April 1, 2003) due to SNF Consolidated Billing and have been removed from this policy.

To show the following:

2. The SNF bill type codes 22X and 23X are not acceptable for this service (services performed on or after April 1, 2003) due to SNF Consolidated Billing and have been removed from this policy. Also, the HCPCS code used by SNFs, J3490, has been removed.

Also under this section, added another paragraph to number 9:

Effective October 01, 2006, the definition of the GS modifier is: “Dosage of EPO or Darbepoetin Alfa has been reduced and maintained in response to hematocrit or hemoglobin level.”

Added numbers 11 – 13:

11. For dates of service April 1, 2006 and later, claims for patients that have opted to receive home dialysis under method 1 or 2 and are self-administering the EPO in their home, are not required to report the GS modifier and therefore, are not subject to the 25-percent payment reduction as described in Change Request (CR) 4135.
12. The HCPCS code Q4081 is effective for services performed on or after January 1, 2007.
13. The HCPCS code J0886 is terminated effective for services performed after December 31, 2006.

© All current procedural terminology (CPT) codes and descriptors copyrighted by the American Medical Association.