EPO: Medicare Reimbursement

• June 1989

  • Medicare EPO coverage
  • Payment is in addition to the composite rate
  • $40 per administration with a $30 supplement for injections of 10,000 units or more
  • Secondary payers typically pay 20% of the EPO allowance
  • Patients who don’t have a secondary payer may have to pay 20% out-of-pocket.

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Medicare Carriers Manual Part 3. Chapter IV - Claims Review and Adjudication Procedures. http://www.hcfa.gov/pubforms/14%5Fcar/3b4271.htm

10-91 CLAIMS REVIEW AND ADJUDICATION PROCEDURES 4273.1 4273. CLAIMS FOR PAYMENT FOR EPOETIN ALFA (EPO)

Effective June 1, 1989, the drug EPO is covered under Part B if administered incident to a physician's services. EPO is used to treat anemia associated with chronic renal failure, including patients on dialysis and those who are not on dialysis.

4273.1 Completion of Initial Claim for EPO.--The following information is required:

Diagnoses, Hematocrit (HCT)/Hemoglobin (Hgb), Units Administered, Date of the patient's most recent HCT or Hg, Most recent HCT or Hgb level prior to initiation of EPO therapy, Date of most recent HCT or Hgb level prior to initiation of EPO therapy, Patient's most recent serum creatinine, within the last month, prior to initiation of EPO therapy, Date of most recent serum creatinine prior to initiation of EPO therapy, Patient's weight in kilograms, Patient's starting dose per kilogram.

Rev. 1406 /Page 4-68.4A