Part A Information

MLN Matters Number: MM6047
Related Change Request (CR) #: 6047
Related CR Release Date: May 16, 2008
Effective Date: October 1, 2008
Related CR Transmittal #: R1503CP
Implementation Date: October 6, 2008

Revisions to the Billing Requirements for ESRD-Related Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) Administrations Provided During Unscheduled or Emergency Dialysis Treatments in the Outpatient Hospital Setting

Provider Types Affected
Hospitals submitting claims to Medicare contractors (fiscal intermediaries (FI) and/or Part A/B Medicare administrative contractors (A/B MAC)) for dialysis services provided to Medicare beneficiaries

Impact on Providers
This article is based on Change Request (CR) 6047 which revises the billing of End-Stage Renal Disease (ESRD) related Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) administrations provided during unscheduled or emergency dialysis treatment in an outpatient hospital setting.

Background
CR 3184 dated June 4, 2004 established Medicare system edits that require the presence of hospital emergency room visit revenue code 045X in order to allow payment for End-Stage Renal Disease (ESRD) related Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) provided in conjunction with an emergency dialysis treatment. Effective October 1, 2008, revenue code 045X will no longer be required in order to allow for EPO and Aranesp payment related to an unscheduled or emergency dialysis treatment.

CR 6047 revises current Medicare system edits associated with unscheduled and emergency dialysis treatments in the hospital outpatient setting to allow for the payment of EPO and Aranesp, Healthcare Common Procedure Coding System (HCPCS) Q4081 and J0882 only when HCPCS G0257 is present on the same claim.

The definition for HCPCS code G0257 is as follows: Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility.
CR 6047 instructs Medicare contractors to:

• Only make payment for ESRD-related EPO or Aranesp in the outpatient hospital setting (13X and 85X bill types) when HCPCS code G0257 appears on the same claim, and
• Return to the provider any outpatient hospital claims containing ESRD-related EPO or Aranesp when HCPCS code G0257 does not appear on the same claim.

Additional Information
The official instruction, CR 6047, issued to FIs and A/B MACs regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1503CP.pdf on the CMS Web site.

If you have any questions, please contact your FI or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site

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