Erythropoietin Stimulating Agents (ESA)

November 27th, 2017 - Wyn Staheli, Director of Research

Categories: Documentation Guidelines Billing Modifiers

Coverage

ESA is typically covered for the following condition(s):

Treatment of anemia associated with chronic renal failure (whether or not that patient is on dialysis)
Treatment of significant anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy
Treatment of anemia due to AZT and/or other Nucleoside Reverse Transcriptase Inhibitors (NRTI) used in treatment of HIV/AIDS
Treatment of selected patients with anemia related to myelodysplastic syndrome
Preoperative adjuvant therapy (epoetin alfa only)
Treatment of anemia of certain chronic diseases (e.g., rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel diseases, and hepatitis C undergoing treatment)

It could also be covered as preoperative treatment for patients undergoing a surgery (e.g., knee or hip replacement) when both the following are met:

patient is expected to lose more than 2 units of blood
patient has anemia and is not a good candidate for transfusions

Documentation

Before beginning ESA therapy, be sure to document (where applicable) any underlying causes of anemia which have been considered, and corrected where possible, such as:

Underlying infection or inflammatory process
Underlying hematological disease
Hemolysis
Vitamin deficiencies (e.g. folic acid or B12)
Blood loss
Aluminum intoxication

Comprehensive assessment which includes the following:

Hematocrit or hemoglobin
Serum iron
Transferrin saturation; or serum ferritin and /or documentation of iron stores in bone marrow
Creatinine
Bone Marrow Biopsy (for myelodysplastic disease or where otherwise indicated)
Erythropoietin level (for myelodysplastic disease; AZT therapy, anemia of chronic disease)

Commonly Associated Modifiers: AY, EA , EB, EC, ED, EE, GS, JA, JB

Billing Note

Medicare will generally only covers ESRD-related drugs and biologicals when be billed by the renal dialysis facility. However, if an ESRD-related drug or biological was furnished to an ESRD beneficiary for reasons other than for the treatment of ESRD, it may be billed separately using modifier AY.

ESRD-related EPO is included in ESRD payment system and thus are not separately payable via Part B claims, however, there can be an exception for hospital billing when there is an emergency or unscheduled dialysis session.

Payer Guidelines

Be sure to verify coverage and review treatment policies with individual commercial payers or your Medicare Administrative Contractor (MAC) before beginning treatment. To review your MAC-specific carrier LCD, check the [Medicare Policies & Guidelines] portion shown below the code.

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Questions, comments?

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