The EC modifier can be used to to determine the prevalence and severity of anemia associated with cancer therapy. Below the description, billing guidelines and reimbursement for this modifier.
What Is Modifier EC?
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.
When To Use An EC Modifier?
Effective for claims with dates of service on and after January 1, 2008, non-ESRD ESA services for HCPCS J0881 or J0885 billed with EC modifier (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;
- B-12 deficiency;
- iron deficiency;
- anemia associated with the treatment of acute and chronic myelogenous leukemias; or
- erythroid cancers.
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.
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 corresponding anemia code must also be billed.
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.