Author Topic: esa stimulating agents coding for 238.72 myelodysplastic syndrom to medicare  (Read 1899 times)

cgestay

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Hi, longtime listener, first time poster. I am a part b New York Oncology provider. Ever since Medicare updated their lcd policy (l25211) earlier this year, I can't get J0881 aranesp or J0885 Procrit paid by medicare for icd-9 238.72. The lcd states 238.72 should be primary dx. I have billed out like this and I never get paid, even changed to 284.89 as primary or secondary dx to 238.72 and still no luck. Medicare is of no help. Wait forever on phone, I get no assistance or I am told to add an RT or LT modifier but that can't be right and it got denied anyway. I am told to appeal but the process takes 2 months or more. Is there something I am doing wrong, I've read the LCD a million times. I have the HCT level, I have the EA modifier. I bill with 90772. I don't know what I'm doing wrong...Please help....thanks

Michele

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Are you reporting the most recent hemoglobin or hematocrit test results in box 19?  Are the claims going in electronically or on paper?  Also, what is the code of the rejection on the Medicare eob? 

Sorry for all the questions, but I need more info.

Michele
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cgestay

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sorry for delay, did not see replay until 9/30. I receive co-16 denial code with remarks ma 130, and n395. I put hct levels in box 19. My system will not let me put hgb in 4 byte value(3 numbers with . between 2nd and 3rd numbers) which is required by Medicare. I also use EA modifier. We bill from a private doctor's office as the facility(11), that is why we use EA modifier. We are not a clinic, lab, or hospital. That is why we don't use EB or EC. Please tell me if my modifier use is the problem. Thank you for your help.

Michele

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I show that the EA, EB & EC modifiers stand for:

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

I don't show that they have anything to do with the place or type of facility.  Is the EA modifier appropriate according to the above description?

If Medicare requires that the hgb be in 4 byte value(3 numbers with . between 2nd and 3rd numbers) then that may be why they are denying.  I can't tell if it is the hgb or the EA modifier with the info I have. 

What is the n395 denial code state?


I'm afraid your only option is to call Medicare.  You need them to tell you specifically why your claim is being denied.

Michele
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