Medicare Compliance & Reimbursement

Don't throw away money for anti-emetic, immunosuppressive drugs. If you're confused about whether you can bill Medicare Part B for oral medications, we have the answer.

Medicare will actually cover a handful of oral medications, but there aren't many, says Suzan Hvizdash, physician educator for the University of Pittsburgh Physicians Department of Surgery and AAPC National Advisory Board Member.

Medicare will cover immunosuppressive drugs, anti-emetic drugs for chemotherapy patients and oral chemotherapy medications that have the same active ingredients as infusion chemotherapy, Hvizdash says.

Most oncology billers may be aware that they could bill for oral medications, but they haven't gone through the process of getting set up to bill, says Bobbi Buell, vice president of provider services and reimbursement with P4 in Menlo Park, CA and executive director of the National Cancer Foundation.

The biggest hurdle facing billers is that they don't have a durable medical equipment (DME) billing number, notes Buell. Physicians can't bill for oral medications without obtaining a separate DME number and billing the DME Medicare Administrative Contractors (MACs).

And four or five states prohibit physicians from dispensing oral medications in their offices, says Buell.

If a physician has a pharmacy in her office, she can bill a "dispensing fee" for oral medications. Medicare introduced two new codes for dispensing oral medications, Q5011-Q5012, this year.

If a physician doesn't have an in-office pharmacy, then she can only bill the DME MAC for the drug itself, using the drug's specific billing code, says Buell. Physicians should contact the drug's manufacturer to find out the correct billing number and make sure Medicare will cover that drug in the doctor's office.

With all of these challenges, many practices are hesitant to bill for oral medications. Southeast Cancer Network in Decatur, AL is considering adding a dispensary to be able to bill the dispensing fee for cancer drugs, says coder Jennifer Rucker. But so far, Southeast Cancer doesn't have a DME number and doesn't bill for any oral drugs.