ESA is typically covered for the following condition(s):
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:
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:
Comprehensive assessment which includes the following:
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.
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.
This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. If you would like to publish this article, please contact us and let us know where you will be publishing it. The easiest way to get the text of the article is to highlight and copy. Or use your browser's "View Source" option to capture the HTML formatted code.
If you would like a specific article written on a medical coding and billing topic, please Contact Us.
Find A Code, LLC
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)