Purpose
The purpose of this bulletin is to provide education to the provider community regarding the new requirements for providing route of administration codes on claims for erythropoiesis stimulating agents (ESAs) administered to end stage renal disease (ESRD) patients.

Background
Patients with end stage renal disease (ESRD) receiving administration of Erythropoiesis Stimulating Agents (ESA), such as Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) for the treatment of anemia, may receive intravenous administrations or subcutaneous administration of the ESA.  Current claims processing requirements do not provide for reporting the method of administration used in providing ESA to patients with ESRD. In order to study the efficacy of both methods of administration, the Centers for Medicare and Medicaid Services (CMS) shall begin requesting providers to voluntarily report modifiers which will indicate the method of administration used in providing the ESA.

At a future date, the shared system modification will be completed and reporting of the route of administration shall be a requirement. Additional instructions will be issued when the shared system changes are completed. Until then, a claim for an ESA that does not report the route of administration shall be paid the same as a claim that does report the route of administration. At this time, a claim for an ESA that does not report and route of administration will not be returned to the provider.

Provider Action
Route of administration modifiers were published and effective January 1, 2007. Consequently, some providers have submitted claims for ESAs reporting the route of administration modifiers.  Effective for claims submitted on or after February 1, 2007 with dates of services on or after January 1, 2007, all providers billing for injections of ESA for ESRD beneficiaries are encouraged to include the modifier JA on the claim to indicate an intravenous administration or modifier JB to indicate a subcutaneous administration, on claims billing Q4081, J0882, or J0886. At this time, reporting these modifiers is voluntary.  Future instructions will be given making inclusion of route on claims billing Q4081, J0882, or J0886 a requirements for ESRD beneficiaries.

All providers billing for injections of ESAs for ESRD beneficiaries will be required to include route of administration when claims processing system changes are completed.  Renal dialysis facility claims including charges for administration of the ESA by both methods must report separate lines to identify the number of administrations provided using each method.

References
Change Request 5480, "New Requirement for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs)" located at: http://www.cms.hhs.gov/transmittals/downloads/R1212CP.pdf

Assistance
If you have any questions regarding this bulletin, please contact the appropriate Customer Contact Center at:

Maryland/DC Providers: 1-866-488-0545
Pennsylvania Providers: 1-800-560-6170

This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.  Additional copies may be downloaded from our website at www.highmarkmedicareservices.com.

Countdown has begun; do you have your NPI? Don't risk disruption to your cash flow - Get your NPI now! National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every healthcare provider needs to get an NPI! Learn more about NPI and how to apply by visiting www.cms.hhs.gov/NationalProvIdentStand/ on the CMS website.

This page also contains a section for Medicare Fee-For-Service (FFS) providers with helpful information on the Medicare NPI implementation.  A Countdown Clock is now available on this page to remind health care providers of the number of days left before the compliance date; bookmark this page as new information and resources will continue to be posted.
For more information on private industry NPI outreach, visit the Workgroup for Electronic Data Interchange (WEDI) NPI Outreach Initiative website at http://www.wedi.org/npioi/index.shtml on the web.