Payment for Epoetin Alfa (EPO) in Other Settings

60.4.4.1 - Payment for Epoetin Alfa (EPO) in Other Settings (Rev. 10640, Issued:08-06-21, Effective:09-07-21, Implementation:09-07-21) With the implementation of the ESRD PPS, ESRD-related EPO is included in ESRD PPS payment amount and is not separately payable on Part B claims with dates of service on or after January 1, 2011 for other providers with the exception of a hospital billing for an emergency or unscheduled dialysis session. In the hospital inpatient setting, payment under Part A is included in the DRG. In the hospital inpatient setting, payment under Part B is made on bill type 12x. Hospitals report the drug units based on the units defined in the HCPCS description. Hospitals do not report value code 68 for units of EPO. For dates of service prior to April 1, 2006, report EPO under revenue code 0636. For dates of service from April 1, 2006 report EPO under the respective revenue code 0634 for EPO less than 10,000 units and revenue code 0635 for EPO over 10,000 units. Payment will be based on the ASP Pricing File. In a skilled nursing facility (SNF), payment for EPO covered under the Part B EPO benefit is not included in the prospective payment rate for the resident’s Medicare- covered SNF stay. In a hospice, payment is included in the hospice per diem rate when treatment is related to the terminal illness. For a service furnished by a physician or incident to a physician’s service, payment is made to the physician by the A/B MAC (B) in accordance with the rules for ‘incident to” services. When EPO is administered in the renal facility, the service is not an “incident to” service and not under the “incident to” provision.