Review Results for Service Specific Post-Payment Review of Darbepoetin Alfa Injection (Non-ESRD Use)

Background

In an effort to reduce the Part B CERT error rate, the MR Department conducted a service specific post-payment review of CPT code J0881 (Darbepoetin alfa injection - non-ESRD use). The primary focus of these audits was to determine whether the medical necessity of the services billed was at the correct code per Medicare guidelines.

National Government Services randomly selected 446 claims billed for CPT J0881 for post-payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

• J0881 – Darbepoetin alfa, 1 microgram (non-ESRD use)

Results

Decision	Number of Claims
Allow	238
Deny	149
Non-Response Denial	59

• 219 claims from Illinois with 109 allowed and 110 denied for a claims error rate of 50.23%
• 146 claim from Minnesota with 78 allowed and 68 denied for a claims error rate of 46.58%
• 81 claims from Wisconsin with 51 allowed and 30 denied for a claims error rate of 37.04%

Key Reasons Services Were Denied

• Documentation did not support medically necessity due to one or more of the following: records did not include signed orders or intent to order; a relevant medical history, hemoglobin and/or hematocrit levels and other pertinent laboratory results; a bone marrow biopsy report and/or other diagnostic studies (when applicable); documentation indicated use for indications other than what is FDA approved
• Documentation was insufficient or incomplete
• Failure to respond to the request for documentation

Recommendations

• Send the requested records within the requested time frame to avoid a denial for no documentation
• Familiarize yourself with available Darbepoetin alfa - non-esrd use guidelines and other CMS publications listed below
• Share this information with your coding personnel to ensure they are properly billing before sending the claim to Medicare.
• If you feel your application of this code is correct, ensure your documentation supports your usage.

Related Content

• SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer Social Security Act, Section 1862
• SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits Social Security Act, Section 1833
• Erythropoietin Stimulating Agents Policies | CMS
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 30, Drugs and Biologicals
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 6 Section 30, Drugs and Biologicals
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Administration of Medications
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 11, Sections:
  • 30.1 Frequency of Dialysis Sessions
  • 30.4 Drugs and Biologicals
  • 30.5 New ESRD Composite Payment Rates Effective January 1, 2005
  • 90 Epoetin (EPO)
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections:
  • 50 Drugs and Biologicals
  • 50.1 Definition of Drug or Biological
  • 50.2 Determining Self-Administration of Drug or Biological
  • 50.3 Incident-to Requirements
  • 50.4.1 Approved Use of Drug
  • 50.4.3 Examples of Not Reasonable and Necessary
  • 50.5.2 Erythropoietin (EPO)
  • 50.5.2.1 Requirements for Medicare Coverage for EPO [home use]
  • 50.5.2.2 Medicare Coverage of Epoetin Alfa (Procrit) for Preoperative Use
• CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1 Part 2 Section 110.21 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Sections:
  • 80.8 Reporting of Hematocrit and/or Hemoglobin Levels
  • >80.9 Required Modifiers for ESAs Administered to Non-ESRD Patients
  • 80.10 Hospitals Billing for Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) for Non-ESRD Patients
  • 80.11 Requirement for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs)
  • 80.12 Claims Processing Rules for ESAs Administered to Cancer Patients for Anti-Anemia Therapy

Posted 12/14/2021