Physicians tips prepared by SHC/LPCH Compliance Department

Before you Prescribe…

Coverage criteria for epoetin and darbepoetin . . .

The issue:
Epoetin alfa (brand names Epogen, Procrit) and Darbepoetin alfa (Aranesp®) are medications commonly prescribed for anemias associated with a variety of illnesses. These two medications have precise coverage criteria for the Medicare patient, such as minimum hematocrit levels, specific types of malignancies, stage III or higher chronic kidney disease, etc. These coverage criteria must be met, and the supporting documentation must be available in your medical records for these patients. If such criteria are not met, your patients could be held financially responsible for the charges associated with the administration of either of these costly medications.

The solution:
Familiarize yourself with the necessary diagnoses, supporting laboratory values, and allowable frequencies for administration of Epoetin and Darbepoetin. Go to:

http://ComplianceFFAT.stanfordmed.org

on the Stanford Intranet for detailed coverage information. Or download a PDF from the Medical Staff Update site:

http://med.stanford.edu/shc/update/coding.htm

For further questions, contact Jean Stone, RHIT, CCS, Facility Fee Auditor/Trainer (650) 724-3849.