Oncology & Hematology Coding Alert

Heads up: The 48-hour rule does not apply to Q0166 and Q0180.

You may find yourself perplexed when your physician uses more than one option or switched from one option to another to control nausea and vomiting in a patient who received chemotherapy. Here is some additional information regarding how you would report multiple drug regimens to control emesis with chemotherapy.

Check for Specific Agents

Chemotherapy has a potential for nausea/vomiting. Guidelines from the American Society of Clinical Oncology (ASCO) state that patients receiving chemotherapy could also receive 5-HT3 receptor antagonists (i.e. ondansetron, granisetron, dolasetron), corticosteroids (dexamethasone) and NK1 receptor antagonists (aprepitant). Drugs like these are effective when used appropriately and your physician can administer these safely in combination. Oral drugs can be as effective as IV options.

Note: “You will find other NK1 antagonists, different coding combinations, etc., but this section describes this concept well on a basic level,” says Leah Fuller, CPC, consultant, Pinnacle Enterprise Risk Consulting Services LLC, in Centennial, Colorado.

The appropriate HCPCS code for aprepitant is J8501 (Aprepitant, oral, 5 mg) and the code used for dexamethasone is J8540 (Dexamethasone, oral, 0.25 mg). The code for the 5-HT3 antagonist will depend on the precise medication prescribed by the physician. Depending on the specific agent prescribed, you may choose from the following codes:

• Q0162 (Ondansetron 1 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)
• Q0166 (Granisetron hydrochloride, 1 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 24 hour dosage regimen)
• Q0180 (Dolasetron mesylate, 100 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 24 hour dosage regimen).

Note: According to the Medicare Claims Processing Manual (Pub 100-04), Chapter 17, Section 80.2, all three drugs in the combination oral anti-emetic regimen need to be submitted on the same claim for proper Part B reimbursement. “Providers subject to the hospital outpatient PPS will be paid on the basis of an APC,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, associate partner, Pinnacle Enterprise Risk Consulting Services LLC.

The three drug regimen – an oral aprepitant (J8501), an oral 5HT3 antagonist (Q0162, Q0166, Q0180) and oral dexamethasone (J8540) is considered reasonable and necessary for patients receiving one or more of the following 9 anti-cancer chemotherapeutic agents (for dates of service on or after April 4, 2005):

• Carmustine (J9050),  
• Cisplatin (J9060),  
• Cyclophosphamide (J8530- oral/J9070- injection),
• Dacarbazine (J9130),
• Mechlorethamine (J9230),
• Streptozocin (J9320)
• Doxorubicin (J9000),
• Epirubicin (J9178), and
• Lomustine (J8999/S0178-oral, not valid for Medicare).

An additional 11 anti-cancer chemotherapeutic agents (for a total of 20 including the 9 listed above) supporting reasonable and necessary criteria for the three-drug regimen were added (for dates of service on or after May 29, 2013):

• Alemtuzumab (J0202),
• Azacitidine (J9025),
• Bendamustine (J9033, J9034, J9036),
• Carboplatin (J9045),
• Clofarabine (J9027),
• Cytarabine (J9098, J9100),
• Daunorubicin (J9150, J9151),
• Idarubicin (J9211),
• Ifosfamide (J9208),
• Irinotecan (J9206), and
• Oxaliplatin (J9263).

And you will find 10 more codes to report for oral anti-emetic treatment if ordered and necessary. These are:

• 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)
• Q0163 (Diphenhydramine hydrochloride, 50 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy treatment not to exceed a 48 hour dosage regimen)
• Q0164 (Prochlorperazine maleate, 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)
• Q0167 (Dronabinol, 2.5 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)
• Q0169 (Promethazine hydrochloride, 12.5 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)
• Q0173 (Trimethobenzamide hydrochloride, 250 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)
• Q0174 (Thiethylperazine maleate, 10 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).
• Q0175 (Perphenazine, 4 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)
• Q0177 (Hydroxyzine pamoate, 25 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)
• Q0181 (Unspecified oral dosage form, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for a IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen)

Confirm the 48-hour Note

When ordering oral anti-emetics instead of the IV form with chemotherapy, your physician is substituting one for the other. Doses are given immediately before and within 48 hours after the chemotherapy administration. This also applies to the three-drug regimen. The three-drug combination protocol requires the first dose to be administered before, during, or immediately after the anti-cancer chemotherapy administration. The second day is defined as ‘within 24 hours,’ and the third day is defined as ‘within 48 hours’ of the chemotherapy administration.

Exception: The agents where the 48-hour rule does not apply include granisetron (Q0166) and dolasetron mesylate (Q0180). The code descriptions for administration of these medications indicate for complete replacement of IV anti-emetic therapy, it is to be limited within 24 hours of the chemotherapy administration.

Important: “It is important for you to fully read and understand in which situations, locations and medical needs the oral form of antiemetic medications are billed and to whom,” Loya says.  For complete details of which drugs are billed to the A/B MAC, or carrier and which drugs are billed to the DME MAC please refer to the Medicare Claims Processing Manual (Pub 100-04), Chapter 17, Section 80.2, or search for Transmittal 2931:  http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2931CP.pdf. Providers (HIPAA definition) that bill the DME MAC will require a supplier number issued by the National Supplier Clearinghouse (NSC) in order to submit claims.

Aim for Flawless Claims

To submit billing for oral anti-emetic treatment to Medicare, you should ensure that the anti-emetic billing, meets the following four key criteria:

1. Document the chemotherapy regimen: Always make sure you have documented what chemotherapy the patient is receiving. Some chemotherapeutic agents, like cisplatin, are known to cause vomiting and nausea.

2. Make note of timing of administration of anti-emetic: Since chemotherapeutic regimens are known to be associated with vomiting, your physician may prescribe the use of an anti-emetic immediately before, during, or within 48 hours after administration of the chemotherapy drug.

3. Do not miss the diagnosis coding: Always bill the applicable diagnosis codes. You may report Z51.11 (Encounter for antineoplastic chemotherapy) for any encounter or admission for chemotherapy. You also submit the appropriate diagnosis code for the neoplasm from codes C00.- (Malignant neoplasm of lip) through C80.- (Malignant neoplasms without specification of site) and adding the 4th digit indicating the known type.

4. Submit the oral anti-emetic codes on the same claim form with one of the chemotherapy drug codes: To ensure best documentation and flawless claims, you should submit the oral anti-emetic codes with those for chemotherapeutic agents.