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PROGRAM MEMORANDUM. INTERMEDIARIES/CARRIERS. Department of Health and Human Services. Health Care Financing Administration . Transmittal No. AB-98- 34 Date JULY 1998. Change Request #555. SUBJECT:Modification of Medicare Policy for Erythropoietin (EPO) http://www.hcfa.gov/pubforms/transmit/r5ch34p2.htm
This Program Memorandum replaces past Medicare coverage policy for erythropoietin (EPO) as contained in Program Memoranda AB 97-2, dated February 1997, AB 97-8, dated May 1997, and AB 98-10, dated March 1998. These instructions provided for pre-payment review of claims for EPO where the hematocrit level exceeded 36 percent. We have found the pre-payment review of EPO claims has been confusing and controversial. Consequently, disregard the previous instructions on EPO and replace past EPO policies with those contained in this program memorandum.
Effective immediately, do not subject claims for EPO furnished under §1881(b) of the Social Security Act (EPO furnished to End Stage Renal Disease (ESRD) patients on dialysis) to routine pre-payment review. In order to do this, override the edit contained in the intermediary standard systems (Fiscal Intermediary Standard System (FISS) (formerly known as the Florida Shared System) and the Arkansas Part A Standard System (APASS)). Claims for billing periods beginning on or after March 10, 1998 that were denied based on hematocrit levels may be resubmitted once the edit is disabled.