EPO: Medicare Reimbursement-Hematocrit Measurement Audit (HMA)-

• September 1997

  • Medical justification not accepted for payment when hematocrit > 36%
  • If the current month's hematocrit was greater than 36% and the patient's hematocrit exceeded 36.5% on an historical 90-day "rolling average" basis, reimbursement for the current month would be denied in full

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Program Memorandum. Intermediaries/Carriers. HCFA Pub 60 A/B. Rev. AB-97-8. 05-97. Retrieval Title: AB-97-8.60. SUBJECT: Hematocrit Levels for Erythropoietin (EPO)

Program Memorandum (PM) AB 97-2 notified you of a policy regarding processing of claims for End Stage Renal Disease (ESRD) patients receiving EPO. That PM instructed you to calculate a rolling average hematocrit for claims where the hematocrit level of the patient exceeded 36%. You were instructed to deny payment on claims where the average hematocrit level on claims for services furnished within the last 90 days exceed 36.5%.

Since that instruction, HCFA has received numerous calls requesting clarification of the medical review policies related to EPO therapy. Under previous policy, you were authorized to make payment for claims for EPO therapy where the hematocrit exceeded 36 % if supported by medical documentation. The revised policy stated that such medical review procedures would not be permitted under the new rolling average audit procedures and instructed you to deny claims exceeding an average hematocrit of 36.5%. However, the PM did not explicitly state that the medical review policy in §3907.2 of the Medicare Intermediary Manual was altered.

This PM is to clarify and state explicitly that you are not to review claims exceeding an average hematocrit of 36.5%. Instead, these claims should be automatically denied as not reasonable and necessary. Based on considerable research of the literature and discussions with a noted hematologist at the National Institutes of Health, HCFA is not able to confirm the allegations that there is a medical justification for maintaining sustained hematocrit levels above 36%.