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Modifier EC 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.


Effective for claims with dates of service on and after January 1, 2008, non-ESRD ESA services for HCPCS J0881 or J0885 billed with modifier EC (ESA, anemia, non-chemo/radio) shall be denied when any one of the following diagnosis codes is present on the claim:

- any anemia in cancer or cancer treatment patients due to folate deficiency (281.2),

- B-12 deficiency (281.1, 281.3),

- iron deficiency (280.0-280.9),

- hemolysis (282.0, 282.2, 282.9, 283.0, 283.2, 283.9-283.10, 283.19), or

- bleeding (280.0, 285.1),

- anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML) (205.00-205.21, 205.80-205.91); or erythroid cancers (207.00-207.81).

Effective for 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 EC (ESA, anemia, non-chemo/radio) shall be denied when any of the following is reflected on the claim:

- 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.

Medicare and Modifier EC: The EC modifier should only be reported for those covered indications outlined in the LCD for J0881 and J0885 where the anemia being treated is non-chemo/radio induced. FSCO has discovered that providers are billing the EC modifier for one of the covered cancer diagnosis codes listed above under the EA modifier instructions. By appending the EC modifier to a cancer diagnosis code, the provider is stating that the anemia for that cancer condition is not related to chemotherapy. Anemia of cancer not related to cancer treatment is a nationally non-covered condition per the NCD issued by CMS for non-ESRD ESA use. The following are the appropriate ICD-9 CM diagnosis codes that would apply when billing the EC modifier:

For J0881 - 238.71, 238.72, 238.73, 238.74, 238.75, 238.76, 273.3, 585.1, 585.2, 585.3, 585.4, 585.5, 585.9

For J0885 - 042, 070.54, 070.70, 238.71, 238.72, 238.73, 238.74, 238.75, 238.76, 273.3, 585.1, 585.2, 585.3, 585.4, 585.5, 585.9, V07.8, 714.0

The corresponding anemia code must also be billed.

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 EA & EB


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