Procrit question....again

I have seen a few denials on Procrit in the last couple of weeks and after some research, I see that there was a revision effective mid July. (For Missouri Medicare)

However, I am having a difficult time deciphering exactly how they want the DX codes to be on the claim.

I understand that they want EA modifier for chemo induced anemia and primary DX code 285.3. I thought I understood that they wanted the cancer DX to be listed second, but I am still getting denials on those. Or am I completely wrong on what they require?

And can anyone tell me what they want for MDS Procrit claims, aside from the EC modifier?

Any help you can offer is greatly appreciated.

Thanks so much!
Kristi

re: Procrit question....again

http://www.wpsmedicare.com/j5macpartb/policy/active/local/l31074_inj023.shtml

re: Procrit question....again

Patients With Myelodysplastic Syndromes (MDS) (with EC modifier)
Anemia is observed in 90 percent of individuals with MDS; only 10 to 28 percent of MDS patients with anemia respond to exogenous EPO.
? Medicare will cover EPO use with MDS when all of the following coverage criteria are met:
o Life expectancy is greater than 3 months.
o To avoid transfusions.
o The patient is symptomatic from the anemia (e.g., fatigue, shortness of breath).
o The chart documents that the bone marrow has been reviewed by the clinician and is consistent with a diagnosis of myelodysplastic syndrome.*
? If the marrow blast count is greater than 10 percent, no ESA is covered unless the medical records demonstrate the patient’s diagnosis is not leukemia.
*Note: When a definitive diagnosis may be established on a cytological basis, marrow confirmation is not required.
o The pretreatment hematocrit level is less than 30 percent.
o The pretreatment erythropoetin level is less than 500µU/ml (if performed).
o The patient is classified as Low or Intermediate -1 risk by the International Prognostic Scoring System.
? The patient may be treated until there is no longer a need for transfusions, until he is no longer symptomatic or the hematocrit level is greater than 33 percent.
? If, after the first 12 weeks of EPO therapy, there is no improvement evidenced by a sustained increase in hemoglobin to a level 1-2 g/dL greater than the starting hemoglobin or a 50 percent decrease in the transfusion requirement over at least two months, then further treatment will not be covered. Additionally, Medicare will not cover ESA supplemental use for subsequent hematocrit level greater than 33 percent.
? Patients whose medical records clearly document a clinical need to administer DPO, rather than EPO, may be treated with DPO in accordance with the same MDS coverage criteria as required for administration of EPO.