Erythropoiesis Stimulating Agents (ESAs)- Requirement for Providing Route of Administration Codes

Provider Types Affected
Physicians, providers, and suppliers who bill Medicare contractors (carriers, including durable medical equipment regional carriers (DMERCs) and DME Medicare administrative contractors (DME MACs), fiscal intermediaries (FIs),including regional home health intermediaries (RHHIs), and Medicare administrative contractors (MACs)) for providing ESA administration services to Medicare end stage renal disease (ESRD) beneficiaries.

What You Need to Know
CR 5480, from which this article is taken, instructs all providers and suppliers on the voluntary reporting of route of administration modifiers on claims for Erythropoiesis Stimulating Agents (ESAs) for ESRD beneficiaries. Route of administration modifiers were published and effective January 1, 2007, for reporting on Medicare claims submitted on or after February 1, 2007, for dates of service on or after January 1, 2007. Please see the background section for details.

Background
Current claims processing requirements do not allow you to report the method of administering Erythropoiesis Stimulating Agents (ESA) - such as epoetin alfa (EPO) and darbepoetin alfa (Aranesp) - to treat your end stage renal disease (ESRD) patients who are anemic. However, in order to study the efficacy of both intravenous administration and subcutaneous administration methods of ESA administration, the Centers for Medicare and Medicaid Services (CMS) will begin requesting you to voluntarily report modifiers, which will indicate the method of ESA administration.

Specifically, CR 5480, from which this article is taken, announces that, effective for claims submitted on or after February 1, 2007 (with dates of services on or after January 1, 2007), all providers and suppliers who bill for administering ESA to ESRD beneficiaries (Healthcare Common Procedure Coding System (HCPCS) codes Q4081, J0882, or J0886) are encouraged to include:

• Modifier JA on the claim to indicate an intravenous administration or
• Modifier JB to indicate a subcutaneous administration.

You should be aware that in the future, this reporting of the route of ESA administration will be a requirement, and additional instructions will be issued at that time. But until then, a claim for an ESA that does not report the route of administration will not be returned to the provider, and will be paid the same as a claim that does report the route of administration. Also, be aware that renal dialysis facilities whose claims include charges for ESA administration by both methods should report them in separate lines in order to identify the number of administrations provided by each method.

Additional Information
You can find more information about route of administration codes for Erythropoiesis Stimulating Agents (ESAs) by going to CR 5480, located at http://www.cms.hhs.gov/Transmittals/downloads/R1212CP.pdf on the CMS website. As attachments to this CR, you will find updated Medicare Claims Processing Manual , Chapter 8 (Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims), Section 60.2.3.1 (Requirement for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs)); and Chapter 17 (Drugs and Biologicals), Section 80.11(Requirements for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs)).

If you have any questions, please contact your state's Provider Contact Center.

MLN Matters MM5480