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Modifier EA Usage and Reimbursement - Know when to use


CMS uses this modifier to gather information to determine the prevalence and severity of anemia associated with cancer therapy, the clinical and hematologic responses to the institution of antianemia therapy, and the outcomes associated with various doses of antianemia therapy.


Medicare and Modifier EA: The EA modifier should only be reported when the ESA is being given for anemia resulting from myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia. The corresponding covered ICD-9 CM codes that would apply to the EA modifier are as follows: 140.0-149.9, 150.0-159.9, 160.0-165.9, 170.0-176.9, 179-189.9, 190.0-199.1, 200.0-200.88, 201.00-201.98, 202.00-202.98, 203.00-203.81, 204.00-204.91, 230.0-234.9, 235.0-235.9, 236.0-236.99, 237.0-237.9, 238.0, 238.1, 238.2, 2383, 238.4, 238.5, 238.6, 238.8, 238.9, 239.0-239.9, 273.3. The corresponding anemia code must also be billed. Any other covered diagnosis code listed in the LCD for J0881 or J0885 will be denied if billed with the EA modifier.

Effective for Medicare claims with dates of service on and after January 1, 2008, services for non-ESRD ESA services for HCPCS J0881 or J0885 billed with modifier EA (ESA, anemia, chemo-induced) shall be denied for anemia secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia when a hemoglobin 10.0g/dL or greater or hematocrit 30.0% or greater is reported.

Reimbursement

Payments for ESAs are based on reasonable and necessary determinations established by NCD. Provider may have the beneficiary sign an Advanced Beneficiary Notice, making the beneficiary liable for services not deemed reasonable and necessary and thus not covered by Medicare.

Know more about on the usage of modifiers EB & EC



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