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CodeMap® LCD-L39236

 

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L39236
LCD for Erythropoiesis Stimulating Agents (L39236) DRAFT POLICY DL39237
See related Articles:
A58981-Billing and Coding: Erythropoiesis Stimulating Agents

Contractor Information

Contractor Name: Palmetto GBA - Full list of policies of this Medicare Contractor

Contractor Number: 11201

Contractor Type: MAC A

LCD Information

LCD ID Number: L39236 Status: P-

LCD Title: Erythropoiesis Stimulating Agents

Geographic Jurisdiction: South Carolina Other Jurisdictions

Original Determination Effective Date:

Original Determination Ending Date:

Revision Effective Date:

Revision End Date:

CMS National Coverage Policy:

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Erythropoiesis Stimulating Agents. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations, and rules for Medicare payment for Erythropoiesis Stimulating Agents and must properly submit only valid claims for them.

Title XVIII of the Social Security Act, §1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1842(u) Each request for payment, or bill submitted, for a drug furnished to an individual for the treatment of anemia in connection with the treatment of cancer shall include information on the hemoglobin or hematocrit levels for the individual.

Title XVIII of the Social Security Act (SSA), §1881(b)(1) allows payment for services furnished to individuals who have been determined to have end stage renal disease.

Title XVIII of the Social Security Act (SSA), §1881(11)(B)(I) allows payment for erythropoietin provided by a physician.

CMS Internet-Only Manual Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, §30 Inpatient Hospital Services covered under Part A, Drugs and Biologicals

CMS Internet-Only Manual Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, §10.2 Other Circumstances in Which Payment Cannot be Made Under Part B, §30-Drugs and Biologicals

CMS Internet-Only Manual Publication 100-02, Medicare Benefit Policy Manual, Chapter 11, §20.3 End Stage Renal Disease (ESRD) Drugs and Biologicals, §30.1 Home Dialysis

CMS Internet-Only Manual Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, §120 Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services, Services and Supplies Furnished Incident to Physician’s Services

CMS Internet-Only Manual Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, §§50, 50.1, 50.2, 50.3, 50.4.1, 50.4.3, 50.5.2, 50.5.2.1 and 50.5.2.2 Covered Medical and Other Health Services Drugs and Biologicals

CMS Internet-Only Manual Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, §110.21- Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions

CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 4, §10 Hospital Outpatient Prospective Payment System (OPPS), §20 Reporting Hospital Outpatient Services Using Healhcare Common Procedure Coding System (HCPCS), §50.1 Outpatient Provider Specific File, and §200.2 Hospital Dialysis Services for Patients with and without End Stage Renal Disease (ESRD)

CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 6, §§20, 20.2.1, 20.2.1.1 Services Included in Part A PPS Payment Not Billable Separately by the SNF

CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 7, §100 SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), Epoetin (EPO)

CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 8, §§10.5, 40, 50.1.5, 50.2, 50.2.5, 50.3, 60.2, 60.2.1.1, 60.2.1.2, 60.4, 60.4.2, 60.4.2.1, 60.4.2.2, 60.4.3.1, 60.4.3.2, Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims-Sections

CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 17, §§10, 20.5.8, 40.1, 80.5, 80.8, 80.9, 80.10, 80.11, 80.12 Drugs and Biologicals

CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 30 Financial Liability Protections

NCD for ESAs for Cancer and Related Neoplastic Conditions - CAG-00383N (cms.gov)

National Coverage Analysis (NCA) for Erythropoiesis Stimulating Agents (ESAs) for Treatment of Anemia in Adults with CKD Including Patients on Dialysis and Patients not on Dialysis (CAG-00413N) (cms.gov)

CR 11244 Discontinuing the Erythropoietin Stimulating Agent (ESA) Monitoring Policy System Edits under the End Stage Renal Dialysis Prospective Payment System (ESRD PPS) Effective 01/01/2020 Pub 100-20 - One-Time Notification (PDF) (cms.gov)


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12/08/2022 12:30:44 3.225.221.130


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