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May 27, 2020

Preventing Denials for Iron Sucrose (Venofer) – HCPCS Code J1756

End Stage Renal Disease (ESRD) Prospective Payment System (PPS)

Background

Section 1881(b) (14) of the Social Security Act (the Act) requires the implementation of a bundled PPS for renal dialysis services furnished to Medicare beneficiaries for the treatment of ESRD. All ESRD-related services and supplies are paid via ESRD PPS. As of January 1, 2017, ESRD facilities are able to furnish dialysis services to acute kidney injury (AKI) patients. The provision provides Medicare coverage and payment to both hospital-based and freestanding ESRD facilities for renal dialysis services furnished to beneficiaries with AKI.

Drugs subject to ESRD consolidated billing for anemia management include HCPCS code J1756 (iron sucrose injection). When this service is provided for the treatment of ESRD or AKI, it is included in the ESRD PPS and is NOT separately payable.

Please see the CY 2020 ESRD Consolidated Billing List External PDF (this is NOT an all-inclusive list).  

Proper Billing of HCPCS Code J1756 for ESRD and ESRD Facilities

Iron sucrose injections are payable (when furnished intravenously) for the first line treatment of iron deficiency anemia in patients undergoing chronic hemodialysis who are receiving supplemental erythropoeitin therapy. Providers must submit HCPCS code J1756 with the appropriate explanation of the drug name and the dosage entered on the claim with the 72x type of bill for ESRD beneficiaries. The primary diagnosis code for chronic renal failure and one of the following secondary diagnosis codes for iron deficiency must be entered, as applicable, for the service date.

Chronic Renal Failure (Primary Diagnosis)

  • ICD-10-CM:  N18.3, N18.4, N18.5, N18.6

 Iron Deficiency Anemia (Secondary Diagnosis)

  • ICD-10-CM:  D50.0, D50.1, D50.8, D50.9, D63.1

Proper Billing of HCPCS Code J1756 for AKI and ESRD Facilities

For payment under Medicare, ESRD facilities shall report all items and services furnished to beneficiaries with AKI by submitting (on a monthly basis) the 72x type of bill with condition code 84, which will differentiate an ESRD PPS claim from an AKI claim. In addition, they are required to include revenue code 082X, 083x, 084x, or 085x for the modality of dialysis furnished with the Current Procedural Terminology (CPT) code G0491 (Dialysis procedure at a Medicare certified ESRD facility for Acute Kidney Injury without ESRD). The primary diagnosis code for AKI and one of the following secondary diagnosis codes for iron deficiency must be entered, as applicable, for the service date.

Acute Kidney Injury (Primary Diagnosis)

  • N17.0 (Acute kidney failure with tubular necrosis)
  • N17.1 (Acute kidney failure acute cortical necrosis)
  • N17.2 (Acute kidney failure with medullary necrosis)
  • N17.8 (Other acute kidney failure)
  • N17.9 (Acute kidney failure, unspecified)
  • T79.5XXA (Traumatic anuria, initial encounter)
  • T79.5XXD (Traumatic anuria, subsequent encounter)
  • T79.5XXS (Traumatic anuria, sequela)
  • N99.0 (Post-procedural (acute)(chronic) renal failure)

Iron Deficiency Anemia (Secondary Diagnosis)

•     ICD-10-CM:  D50.0, D50.1, D50.8, D50.9, D63.1

Payment will be made for one treatment per day across settings, except in the instance of uncompleted treatments. This rare occurrence must be fully documented to the Medicare Administrative Contractor’s (MAC) satisfaction. See Acute Kidney Injury and ESRD Facilities.External Website

Proper Use of the AY Modifier

ESRD facilities and other providers should include the AY modifier on claims billed when the services are NOT for the treatment of ESRD or the dialysis services are for non-ESRD reasons.

When a provider other than an ESRD facility provides renal dialysis services to an ESRD beneficiary for reasons not related to the treatment of ESRD, the submitted claim must include the AY modifier to allow for separate payment under Medicare.

Example:  If an ESRD beneficiary also has cancer and has a laboratory test done related to cancer treatment, the laboratory should submit the claim with an AY modifier in order to receive separate payment.

Note:  An item or service furnished by an ESRD facility that is not for the treatment of ESRD must be submitted with an AY modifier to allow for separate payment outside of the ESRD PPS.

References

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