Oncology & Hematology Coding Alert

To bill correctly and get reimbursed for oral anti-cancer drugs and prodrugs, claims should be submitted to a Durable Medical Equipment Regional Carrier (DMERC) on the Health Care Financing Administrations HCFA-1500 claim form for Medicare reimbursements or its electronic equivalent.

Because certain oral chemotherapy drugs recently were approved for Medicare coverage, billing for oral chemotherapies can be a source of uncertainty.

As the use of oral chemotherapy drugs becomes more popular, oncology practices should remember to file claims with their DMERC if they dispense the drugs in their offices. Medicare carriers should not be billed for this chemotherapy, says Samuel M. Silver, MD, PhD, advisor for the American Medical Associations CPT advisory committee and medical director of the Cancer Center Network Initiative at the University of Michigan.

Medicare and most payers dont pay for self-administered drugs. Under Medicare, for example, billers may be tempted to submit claims to their fiscal intermediary using CPT and HCPCS codes when they should be using the appropriate National Drug Code (NDC) set forth by the DMERC. (See box of NDC numbers and their descriptors on page 12.)

To make matters more confusing, the federal Omnibus Budget Reconciliation Act of 1993 authorized Medicare to cover anti-cancer pills that are self-administered. These drugs, however, have to contain the same active ingredients as injectable chemotherapy, says Laurie Lamar, RHIA, CCS, CTR, CCS-P, a reimbursement specialist with the American Society of Clinical Oncology in Alexandria, Va.

Just such a type of oral chemotherapy, known as prodrugs, is emerging. When metabolized, these drugs have the same active ingredients in the body as injectable anti-cancer drugs. The prodrug capecitabine, for example, mimics the continuous intravenous infusion of fluropyrimidine 5-FU, a drug used to treat breast and colorectal cancers. Since January 1999, Medicare has included certain prodrugs for coverage, Lamar says. Medicares oral anti-cancer drug benefits cover cyclophosphamide, etoposide, methotrexate and melphalan, which all contain the same active ingredients as injectable chemotherapies.

Capecitabine recently was added to the coverage list.

Handling the Claim

Unlike other drugs billable to a DMERC, these oral anti-cancer drugs should not be billed using HCPCS codes.
Oral anti-cancer drugs are billed using the NDC number.

Unless an oncology practice already bills a DMERC for durable medical equipment such as pumps, its likely the practice doesnt have a supplier number, Lamar says.

Doctors might be more inclined to get a DMERC number because the convenience of oral chemotherapy might make oral chemotherapy more popular.

Claims for specific oral anti-cancer prodrugs must include a cancer diagnosis, such as 174.9 (breast cancer), on the claim form, and the physician/supplier must be allowed by his or her state law to dispense prescription drugs under a valid MD or pharmacy license.

Filing [...]