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36.4.20.17 Hematopoietic Agents
Providers requesting reimbursement for epoetin alfa for the treatment of anemia associated with end-stage renal disease (ESRD) may use procedure code 1-J0886. Providers requesting reimbursement for darbepoetin alfa for the treatment of anemia associated with ESRD may use procedure code 1-J0822. When submitting procedure code 1-J0822 or 1-J0886 for consideration of reimbursement, providers must enter in the comments section of the claim the client's most recent dated hematocrit levels that clearly indicate the client's hematocrit was not equal to or greater than 37 percent.
Erythropoietin Alfa (EPO)
Medicaid reimbursement is allowed for EPO injections administered to chronic renal disease patients, chronic end-stage renal disease predialysis patients who have an anemia with a Hematocrit of 36 percent or less, and for patients with human immunodeficiency virus (HIV) infection who are being treated with zidovudine (AZT). Payment is limited to the end-stage renal dialysis facility and the physician in the office. Only three injections are allowed per calendar week (Sunday through Saturday).
EPO is a glycoprotein that stimulates red blood cell formation and production of the precursor red blood cells of the bone marrow. EPO is indicated for:
• Anemia associated with chronic renal failure, including patients on dialysis (end-stage renal disease) and patients not on dialysis (in chronic end-stage renal disease patients, the increased blood, urea, nitrogen (BUN) impairs the production of erythropoietin, leading to a chronic anemia).
•Anemia related to therapy with AZT in HIV-infected patients.
•Anemia due to the effects of concomitantly administered chemotherapy in patients with non-myeloid malignancies.
•Anemia related to rheumatoid arthritis.
Procedure code 1-J0885 must be submitted with one of the following diagnosis codes to be considered for reimbursement:
Procedure code 1-J0886 must be submitted with one of the following diagnosis codes to be considered for reimbursement:
Important: EPO given for a hematocrit of 37 percent or above is not a benefit of the Texas Medicaid Program.
Darepoetin Alfa
Darbepoetin alfa is an erythropoiesis-stimulating protein closely related to erythropoietin. Darbepoetin stimulates erythropoiesis by the same mechanism as endogenous erythropoietin (EPO). Erythropoietin is produced in the kidney and released into the bloodstream in response to hypoxia. It interacts with progenitor stem cells to increase erythrocyte production.
Darbepoetin alfa may be considered for reimbursement when submitted using procedure codes 1-J0881 and 1-J0882. Darbepoetin is limited to 500 units per day (500mcg). The injection should be administered once a week if the patient is receiving Epoetin alfa 2 to 3 times weekly, and once every 2 weeks if the patient is receiving EPO alfa once per week.
Procedure code 1-J0881 must be submitted with one of the following diagnosis codes to be considered for reimbursement:
Procedure code 1-J0882 must be submitted with one of the following diagnosis codes to be considered for reimbursement:
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