Oncology & Hematology Coding Alert

Keep in mind the 48-hour period timeline.

You may miss out on payment if you ignore essentials for oral anti-emesis, like the allowable period of covered therapy, documentation for chemotherapy, and substitution of intravenous options. You report code Q0161 (Chlorpromazine hydrochloride, 5 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen) for oral chlorpromazine. This code applies to 5 mg dose of chlorpromazine over a 48 hour period. Here is more about this code to help you avoid denials on your claims. 

Watch the Medicare Mandate: You submit claims for chlorpromazine using a Q code. You should make sure your physician indicates on the order the beneficiary is receiving the oral antiemetic drug(s) as full therapeutic replacement for an intravenous anti-emetic drug as part of a cancer chemotherapeutic regimen. This is a mandate for the Medicare benefit. 

Follow 4 Tips For Q0161

Keep the following four important tips in mind when reporting Q0161:

1. Make sure it’s for full therapeutic replacement: Medicare pays for oral anti-emetic drugs when used as full therapeutic replacement for intravenous dosage forms as part of a cancer chemotherapeutic regimen. The oral anti-emetic should be administered or prescribed by a physician for use immediately before, at, or within 48 hours after the time of administration of the chemotherapeutic agent. 

2. Keep in mind the 48- hour period: The allowable period of covered therapy includes the date of service of the chemotherapy drug (day one counted as beginning at the time of treatment), plus a period not to exceed two additional calendar days, or a maximum period up to 48 hours. 

3. Document the chemotherapy: You can report the oral anti-emetic drug(s) which are prescribed by your physician only on a per-chemotherapy-treatment basis. In this scenario, you report code V58.11 (Encounter for antineoplastic chemotherapy) as your primary diagnosis code. This makes it clear the patient presented for chemotherapy.  

“Be sure to refer to the NCD and policy articles from your MAC to verify the chemotherapeutic agent is included. The oral therapeutic replacement ‘is considered reasonable and necessary for only those patients who are receiving’ the medications listed in the policy,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc.

4. Watch the units: Report one unit of Q0161 for 5 mg of chlorpromazine.

Note: For more details on the Medicare directive, refer to http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2931CP.pdf.