Hematocrit Hemoglobin Reporting

Question: Could you please check the requirements on the reporting of value codes reflecting the most recent hematocrit or hemoglobin levels when certain ESA HCPCS are present? These would be reported in the 2400/MEA segment in the 837 professional format. I need to know if I need it for a SNF setting.

Answer: Yes, nursing homes and skilled nursing facilities are also required to report this using value codes 48 (reports the hemoglobin reading) or 49 (reports the hematocrit reading); if they are not present, the claims will be returned.

The two most specific areas that answer this question, from MLN Matters Article #5699, are:

Provider Types Affected

• Physicians, providers, and suppliers who bill Medicare Carriers, including Durable Medical Equipment Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), Competitive Acquisition Plan (CAP) Designated Carriers, and Part A/B MACs for providing ESAs and related anti-anemia administration services to Medicare beneficiaries

and:

• In a skilled nursing facility:
  • ESAs when administered by a renal dialysis facility, are covered under the Part B EPO benefit and are not included in the prospective payment rate for a Medicare covered SNF stay; (PUB 100-4, Chapter 6, §20.2.1.1)
  • ESAs when not part of the ESRD benefit are included in the prospective payment rate for a Medicare covered SNF stay ['SNF HCPCS Help File,' PUB 100-4, Chapter 6; MedLearn Memo Article SE0434, 'Skilled Nursing Facility Consolidated Billing and Erythropoietin (EPO, Epoetin Alfa) and Darbepoetin Alfa (Aranesp).']
  • Skilled Nursing Facilities cannot be paid for Darbepoetin alfa administered to a non-ESRD beneficiary in a part B stay.

Because Medicare doesn't specifically rule out skilled nursing facilities or nursing homes, this means they are held to the same rules as everyone else.