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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : 9.2.39.20 Hematopoietic Injections

9.2.39.20
Hematopoietic agents erythropoietin alfa or epoetin alfa (EPO) and darbepoetin alfa are benefits of Texas Medicaid and reimbursed using procedure codes J0881, J0882 and J0885 and an appropriate diagnosis code.
Providers must maintain medical records in their offices that document regular monitoring of hemoglobin or hematocrit levels and explain the rationale for the dosing of epoetin alfa and darbepoetin alfa. These records are subject to retrospective review to determine appropriate utilization and reimbursement for this service.
When billing procedure code J0882 providers must submit the client’s most recent dated hemoglobin or hematocrit levels in the comments section of the claim form.
EPO and darbepoetin alfa injections are limited to specific diagnosis codes as indicated in this section.
Refer to:
Subsection 6.2.9.4, “Hematopoietic Injections” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for information about outpatient facility criteria.
9.2.39.20.1
EPO (procedure code J0885) is a glycoprotein that stimulates the formation of red blood cells and the production of the precursor red blood cells of the bone marrow. EPO is indicated for:
Procedure code J0885 must be billed with one of the following diagnosis codes:
 
EPO may be considered for reimbursement when the dose is titrated consistent with prevailing, evidence-based clinical guidelines, as published by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative, including appropriate monitoring of the rise and fall of the hemoglobin or hematocrit levels.
EPO is limited to three injections per calendar week (Sunday through Saturday).
9.2.39.20.2
Darbepoetin alfa (procedure codes J0881 and J0882) is an erythropoiesis-stimulating protein closely related to erythropoietin. Darbepoetin stimulates erythropoiesis by the same mechanism as EPO. Darbepoetin alfa has approximately a three-fold longer half-life than EPO, resulting in a sustained erythopoietic effect and less frequent dosing. Darbepoetin alfa is indicated for:
Procedure code J0881 must be billed with one of the following diagnosis codes:
 
Procedure code J0882 must be billed with one of the following diagnosis codes:
 
Darbepoetin is limited to 100 units per day (100 mcg). Darbepoetin should be administered as follows:

Texas Medicaid & Healthcare Partnership
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