10/03/2024

ESA agent denials: impacting Medicare PPO - Message From BCBSM

ESA Agent Denials: Impacting Medicare PPO

BCBSM has determined that claims are denying due to the modifiers that are billed incorrectly on the claims.

BCBSM follows LCD/NCD guidelines, which are linked below.

LCD L34633 - LCD - Erythropoiesis Stimulating Agents (ESAs) (L34633) (cms.gov)

LCA A56795 - Article - Billing and Coding: Erythropoiesis Stimulating Agents (ESAs) (A56795) (cms.gov)

Effective January 1, 2008, all non-ESRD claims billing HCPCS Q5106, J0881 and J0885 must begin reporting one of the following modifiers: EA, EB, or EC.

Additionally, all non-ESRD claims reporting HCPCS code J0881, J0885, J0888, or Q5106 and all ESRD claims reporting J0882, J0887, Q4081, and Q5105 must also be reported with 1 and only 1 of the following modifiers: JA, JB, JE.

If you have any questions, please reach out to MSHO at billing@msho.org