Pharmacy Question for the Week of May 22, 2017

Pharmacy Compliance Question of the Week

Question:

What modifiers are required for claims submitted for ESAs administered to non-ESRD patients (J0881 and J0885)?

Answer:

According to the Centers for Medicare & Medicaid Services (CMS), all non-ESRD claims billing HCPCS level II code J0881 (Injection, darbepoetin alfa, 1 microgram [non-ESRD use]) and J0885 (injection, epoetin alfa, [for non-ESRD use], 1000 units) must report one of the following modifiers:

  • EA: ESA, anemia, chemo-induced
  • EB: ESA, anemia, radio-induced
  • EC: ESA, anemia, non-chemo/radio

Institutional claims that do not report one of the above modifiers will be returned to the provider.

Professional claims that are billed without the required modifiers will be returned as unprocessable.

The above information can be found in the Medicare Claims Processing Manual, Chapter 17, section 80.9.

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.