An erythropoiesis stimulating agent (ESA) is a manufactured analog of the naturally occurring hormone, erythropoietin, developed to produce the same effect. This article addresses the coding of selected items addressed by the NCD for use of ESAs in cancer and related neoplastic conditions.

As per Change Request (CR) 5818, the following are Nationally Non-Covered Indications:

• Any anemia in cancer or cancer treatment patients due to bone marrow fibrosis,
• Anemia of cancer not related to cancer treatment,
• Prophylactic use to prevent chemotherapy-induced anemia,
• Prophylactic use to reduce tumor hypoxia,
• Patients with erythropoietin-type resistance due to neutralizing antibodies, and
• Anemia due to cancer treatment if patients have uncontrolled hypertension.

Because there are no specific ICD-9-CM codes for the indications above, they will be indicated on the claim submitted to this contractor with assigned ICD-9-CM code V49.89. This will indicate that the patient has a non-covered condition(s) listed in Business Requirement (BR) 5818.1.1.

Please see the additional references listed below for further information.

CMS Publication, IOM 100-03, Medicare National Coverage Determinations (NCD) Manual, Transmittal No. 80, Change Request #5818, January 14, 2008, describes the NCD for the use of ESAs in Cancer and Related Neoplastic Conditions.

CMS Publication, IOM 100-04, Medicare Claims Processing Manual, Transmittal No. 1413, Change Request #5818, January 14, 2008, describes the coding and claims processing rules for the use of ESAs in Cancer and Related Neoplastic Conditions.

CMS Publication, IOM 100-04, Medicare Claims Processing Manual, Transmittal No. 1412, Change Request #5699, January 11, 2008, describes the coding and claims processing rules for the Reporting of Hematocrit or Hemoglobin Levels on All Claims for the Administration of Erythropoiesis Stimulating Agents (ESAs), Implementation of New Modifiers for Non-ESRD Indications, and Reporting of Hematocrit/Hemoglobin Levels on all Non-ESRD, Non-ESA Claims Requesting Payment for Anti-Anemia Drugs.

Bill Type Codes

Revenue Codes

ICD-9 Codes that Support Medical Necessity

This contractor considers the ICD-9-CM code listed below to indicate that the patient has a nationally non-covered condition(s) for the use of ESAs in cancer and related neoplastic conditions, as per BR 5818.1.1.