Clarification and Update to Hospital Billing Instructions and Payment for Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) for Beneficiaries with End Stage Renal Disease (ESRD)
Effective January 1, 2006 the definition of value code 49 is changed to report the most recent hematocrit reading taken before the start of the billing period. Since it is not expected that hospitals will have a reading before the start of their billing period, hospitals will no longer be required to report the value code 49 when submitting claims for EPO or Aranesp. Also, effectiave January 1, 2006 the codes for EPO and Aranesp (Q4055 and Q4054) are being terminated and replaced with J0886 for EPO and J0882 for Aranesp. The CMS Medicare Benefit Policy Manual 100-2, Chapter 6, Section 10 provides for the coverage of Epoetin Alfa under the inpatient Part B benefit. Currently, when hospitals bill for Q4055 on their inpatient Part B claims (type of bill 12x), it must be reported under the revenue code 0636. This is contrary to their billing of Q4055 on the hospital outpatient claims (type of bill 13x) that requires the use of the revenue codes 0634 and 0635. For consistency of hospital reporting of Q4055 (replaced with J0886 effective January 1, 2006), with the implementation of this instruction, hospitals will begin using the revenue code 0634 for EPO less than 10,000 units and revenue code 0635 for EPO over 10,000 units when billing J0886 under the inpatient Part B benefit on bill type 12x. The total number of units as a multiple of 1000 units is placed in the units field.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: October 31, 2005
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