HCPCS Modifier EB

Published 07/16/2020

Description
Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer radiotherapy.

HCPCS Procedure Codes

  • J0881
  • J0885
  • Q5106

Guidelines/Instructions

  • Non-end-stage renal disease (non-ESRD) claims for the administration of erythropoiesis stimulating agents (ESAs) must contain one of the following HCPCS modifiers: EA, EB or EC. Non-ESRD claims for ESAs submitted without one of these modifiers will be rejected and must be corrected and resubmitted.
  • Report only one ESA modifier with each appropriate procedure code. If the ESA is submitted with multiple ESA modifiers, it will be rejected. 
  • Hematocrit and/or hemoglobin levels are required for the administration of ESAs or will be rejected.
  • For electronic claims, report the most recent hematocrit or hemoglobin level in Loop 2400 MEA segment. Specifically: MEA01=TR (for test results), MEA02=R1 (for hemoglobin) or R2 (for hematocrit), and MEA03=the test results. Enter the test results as follows: TR=test results, R1=hemoglobin or R2=hematocrit (a two position alpha-numeric element), and the most recent numeric test result (a three position numeric element [xx.x]).
  • For paper claims, report the most recent hematocrit or hemoglobin level in Item 19 of the CMS-1500 claim form

References

  • CMS MLN Matters article MM5699 (PDF, 74 KB): Reporting of Hematocrit or Hemoglobin Levels on All Claims for the Administration of Erythropoiesis Stimulating Agents (ESAs), Implementation of New Modifiers for Non-ESRD ESA Indications, and Reporting of Hematocrit or Hemoglobin Levels on all Non-ESRD, Non-ESA Claims Requesting Payment for Anti-Anemia Drugs
  • CMS transmittal 1413, Change Request 5818 (PDF, 209 KB)
  • CMS National Coverage Determination 110.21 - for Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
  • CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 17, Section 80.8-80.12 (PDF, 492 KB) 
  • CMS Medicare Benefit Policy Manual (Pub. 100.02), Chapter, Section 50