Pharmacy Question for the Week of November 26, 2018

Pharmacy Compliance Question of the Week

Question:

Our cancer center sees a lot of patients with a diagnosis of anemia in chronic kidney disease (CKD). These patients come to the cancer center for Procrit injections. We want to verify if it is appropriate to bill J0885 for the Procrit and a diagnosis code of D63.1 (anemia in CKD) along with the CKD. We were told that only a nephrologist should bill D63.1 along with the J0885. There is no mention of this in national coverage determination (NCD) policy 110.21 (ESAs in cancer and related neoplastic conditions). Please verify if this information is correct.

Answer:

Neither NCD policy 110.21 nor the Medicare Claims Processing Manual (sections 80.8–80.12) contain information specific to physician specialty. Institutional and outpatient providers may bill ICD-10-CM diagnosis code D63.1 with an applicable CKD diagnosis code when documentation is present in the medical record. Per coding guidelines, the Medicare Administrative Contractors (MACs) require the CKD diagnosis to be listed first with the anemia diagnosis code listed secondarily.

For this information, go to the following sources: https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/esapolicies.html and https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.