Does J0888 require prior authorization?

Yes, J0888 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J0888?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J0888`, Injection, epoetin beta, 1 microgram, (for non esrd use)

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.
Medical record must include most recent blood pressure and demonstrate reasonable control, weight in kilograms, date and results of Hb or HCT prior to ESA administration, and assessment that other causes of anemia are ruled out or managed.
Every page of the medical record must be legible with patient identification, dates of service, and the legible signature of the responsible physician or non-physician practitioner; submitted records must support the selected ICD-10-CM and CPT/HCPCS codes.
Non-ESRD claims for J0881, J0885 and Q5106 must include one of modifiers EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio); all applicable ESA claims must report exactly one route modifier: JA (IV), JB (subcutaneous), or JE (via dialysate).
Claims must report the most recent Hb or Hct reading on the claim: institutional claims use value code 48 (Hb) or 49 (HCT); professional paper claims place results in item 19 of CMS-1500; electronic 837P claims use Loop 2400 MEA with MEA01=TR, MEA02=R1 (Hb) or R2 (HCT), and MEA03=the test result.
Documentation: Prior to ESA/PEG-epoetin beta initiation, document iron stores, ferritin, and TSAT and ensure they are maintained in normal physiologic ranges.

Key Coverage Criteria

ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.
ESAs may be considered medically necessary for treatment of anemia related to CKD only if: iron stores (ferritin >=100 ng/mL or TSAT >=20%) are maintained, the ESA dose is the lowest dose to reduce RBC transfusions, and blood pressure is controlled, with drug-specific criteria also met.
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).

20 Active Policies

WPS-J5-L34633, Erythropoiesis Stimulating Agents (ESAs)

A56795, Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)

NGS-J6-L40333, Erythropoiesis Stimulating Agents

NGS-J6-L40334, Erythropoiesis Stimulating Agents

WPS-J8-L34633, Erythropoiesis Stimulating Agents (ESAs)

PALMETTO-JJ-L39237, Erythropoiesis Stimulating Agents

NGS-JK-L40334, Erythropoiesis Stimulating Agents

NGS-JK-L40333, Erythropoiesis Stimulating Agents

PALMETTO-JM-L39237, Erythropoiesis Stimulating Agents

BCBSLA-00210-60A0AB5406, 00210 Erythropoiesis-Stimulating Agents (ESA’s): epoetin alfa (Epogen and Procrit), epoetin alfa-epbx (Retacrit), darbepoetin alfa (Aranesp), and pegylated epoetin beta (Mircera)

BCBSM-2087267-5B75D2C250, MIRCERA (retired as of 06/10/2021)

HEALTHNET_OR-HNOR-METHOXY-POLYETHYLENE-GLYCOL-EPOETIN-BETA-MIRCERA-CP-PHAR-1FC57BEA40, Methoxy polyethylene glycol-epoetin beta (Mircera); CP.PHAR.238

BCBSMT-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)

BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care

BCBSNM-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents

SUREST-POL-SUREST-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents

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J0888, Injection, epoetin beta, 1 microgram, (for non esrd use)

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.
Medical record must include most recent blood pressure and demonstrate reasonable control, weight in kilograms, date and results of Hb or HCT prior to ESA administration, and assessment that other causes of anemia are ruled out or managed.
Every page of the medical record must be legible with patient identification, dates of service, and the legible signature of the responsible physician or non-physician practitioner; submitted records must support the selected ICD-10-CM and CPT/HCPCS codes.
Non-ESRD claims for J0881, J0885 and Q5106 must include one of modifiers EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio); all applicable ESA claims must report exactly one route modifier: JA (IV), JB (subcutaneous), or JE (via dialysate).
Claims must report the most recent Hb or Hct reading on the claim: institutional claims use value code 48 (Hb) or 49 (HCT); professional paper claims place results in item 19 of CMS-1500; electronic 837P claims use Loop 2400 MEA with MEA01=TR, MEA02=R1 (Hb) or R2 (HCT), and MEA03=the test result.
Documentation: Prior to ESA/PEG-epoetin beta initiation, document iron stores, ferritin, and TSAT and ensure they are maintained in normal physiologic ranges.

Key Coverage Criteria

ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.
ESAs may be considered medically necessary for treatment of anemia related to CKD only if: iron stores (ferritin >=100 ng/mL or TSAT >=20%) are maintained, the ESA dose is the lowest dose to reduce RBC transfusions, and blood pressure is controlled, with drug-specific criteria also met.
This policy addresses only the determination of medical necessity for the hospital outpatient setting for infusion and injectable therapy; the medical necessity of the pharmacologic or biologic medication itself may be reviewed separately.
Requests for select medications intended for administration in a hospital outpatient setting will be directed to a preferred alternative site of care (non-hospital affiliated outpatient facility or home).

20 Active Policies

WPS-J5-L34633, Erythropoiesis Stimulating Agents (ESAs)

A56795, Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)

NGS-J6-L40333, Erythropoiesis Stimulating Agents

NGS-J6-L40334, Erythropoiesis Stimulating Agents

WPS-J8-L34633, Erythropoiesis Stimulating Agents (ESAs)

PALMETTO-JJ-L39237, Erythropoiesis Stimulating Agents

NGS-JK-L40334, Erythropoiesis Stimulating Agents

NGS-JK-L40333, Erythropoiesis Stimulating Agents

PALMETTO-JM-L39237, Erythropoiesis Stimulating Agents

BCBSM-2087267-5B75D2C250, MIRCERA (retired as of 06/10/2021)

HEALTHNET_OR-HNOR-METHOXY-POLYETHYLENE-GLYCOL-EPOETIN-BETA-MIRCERA-CP-PHAR-1FC57BEA40, Methoxy polyethylene glycol-epoetin beta (Mircera); CP.PHAR.238

BCBSMT-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)

BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care

BCBSNM-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.069, Erythropoiesis-Stimulating Agents (ESAs)

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UMR-POL-UMR-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents

SUREST-POL-SUREST-erythropoiesis-stimulating-agents, Erythropoiesis-Stimulating Agents

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about J0888 Sign up free

`J0888`, Injection, epoetin beta, 1 microgram, (for non esrd use)

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0888`, Injection, epoetin beta, 1 microgram, (for non esrd use)

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0888, Injection, epoetin beta, 1 microgram, (for non esrd use)

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J0888, Injection, epoetin beta, 1 microgram, (for non esrd use)

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J0888`, Injection, epoetin beta, 1 microgram, (for non esrd use)

`J0888`, Injection, epoetin beta, 1 microgram, (for non esrd use)