Anemia for Erythropoiesis Stimulating Agents (ESA) Erythropoiesis Stimulating Proteins - Epoetin Alfa (EPO), Darbepoetin Alfa (DPA)
WPS Medicare recently received two questions regarding anemia related to ESA. The first questioner asked if a patient is anemic prior to initiating chemotherapy, at what point, does a physician determine the cancer, or the chemotherapy causes the anemia. Our response is that the physician determines the cause of the anemia. During the workup for the anemia, the physician determines if the continuing or worsening anemia is due to cancer or chemotherapy. The results of cancer may cause the anemia. Iron deficiency, bleeding, or renal disease, etc., also may cause the anemia.
In the second question, providers asked if Medicare covers ESA, Epoetin alfa (EPO), Darbepoetin alfa (DPA), for patients who were anemic prior to starting chemotherapy. We replied that WPS Medicare does not cover ESA - EPO, DPA for cancer-induced anemia. The anemia must be due to the chemotherapy itself whether the chemotherapy is being used to treat cancer or another illness such as hepatitis, multiple scleroses, etc. Treatment of myeloid malignancies is an exception. Medicare considers reimbursement for ESA - EPO, DPA for chemotherapy-induced anemia.
When billing for chemotherapy-induced anemia, Medicare requires three diagnosis codes. The WPS Medicare Local Coverage Determination INJ-023, "Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)," instructs providers to report 285.8 or 285.9 to indicate the anemia, 995.20 to indicate the chemotherapy, and a third code to indicate the underlying condition.
For additional information on ESA - EPO, DPA, please refer to the WPS Medicare LCD INJ-023 on our Website on the following links:
http://www.wpsmedicare.com/policies/wisconsin/inj023.pdf
http://www.wpsmedicare.com/policies/wisconsin/inj023_billing.pdf
Page Last Updated: Tuesday, 15-Jul-2008 10:45:17 CDT
