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Erythropoietin Stimulating Agents (ESA)

By:  Wyn Staheli, Director of Research
Published:  November 27th, 2017

Coverage

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:

  • 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: AYEA , EBECEDEEGSJAJB

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.


References:

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