Oncology & Hematology Coding Alert

Reimbursement for oral chemotherapy can be a losing proposition because Medicare has a long-standing policy against paying physicians for self-administered drugs dispensed in the office. However, a few oral chemotherapy drugs are eligible for reimbursement in this situation. The key to getting paid is knowing which drugs can be administered in the office, which entity you should submit the claim to -- your local carrier or durable medical equipment regional carrier (DMERC) -- and which codes to use, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, N.H.
 
Medicare Covers Some Self-Administered Drugs 

 

The Omnibus Budget Reconciliation Act of 1993 authorized Medicare to cover some self-administered anti-cancer pills. These drugs, however, have to contain the same active ingredients as injectable chemotherapy, says the American Society of Clinical Oncology's (ASCO) Public Policy and Practice Department in Alexandria, Va. The drugs in this class Medicare now covers are cyclophosphamide, etoposide, methotrexate and melphalan.

To make matters more confusing, a new class of oral chemotherapy drugs has emerged (called "prodrugs") that do not contain the same active ingredients as injectable chemotherapy -- until they are metabolized. For example, Capecitabine, a prodrug, when metabolized, mimics the continuous infusion of 5-FU (J9190). Thankfully, Medicare has covered prodrugs since January 1999.

In April, the FDA approved a new anti-cancer drug, Gleevec, a once-a-day pill aimed at treating patients with chronic myeloid leukemia (CML) who have not responded to standard therapy. Despite its great promise, the Centers for Medicare and Medicaid Services (CMS, formerly called HCFA) says the drug will not be reimbursed, limiting oncologists to simply prescribing the drug and making patients pay for it ($2,000 to $2,400 per month). This is because CMS considers Gleevec a self-administered drug, a category it normally does not reimburse unless the drug is among the few oral chemotherapy drugs Medicare has approved for coverage in physician offices. 

Gleevec's exclusion should not discourage oncologists from seeking reimbursement for other oral anti-cancer drugs they dispense to their Medicare patients. Capecitabine for example, is covered by Medicare. A major caveat for reimbursement is that if oncology practices dispense a drug in the office they must file the claim with their DMERC, using the appropriate national drug code (NDC).

 

Many oncology practices have avoided billing their DMERC because of the red tape involved in getting a provider number and payment delays. "But with oral chemotherapy drugs in the pipeline, I think we all need to figure out a way to deal with the DMERCs," Towle says.

Practices must submit claims for approved oral anti-cancer drugs and prodrugs to a DMERC on form HCFA-1500 or its electronic equivalent. However, you can't bill a DMERC without a supplier number. Unless an oncology practice already bills for durable medical equipment such as pumps, it probably doesn't have a supplier number and will have to apply for one. 

Claims submitted to a DMERC for specific oral anti-cancer prodrugs must include a cancer diagnosis on the claim form and state law must allow the physician or supplier to dispense prescription drugs and have a valid license to do so.

 

For example, Cigna Healthcare Medicare Benefits Administration, a fiscal intermediary and DMERC, instructs its providers to include the following information on the HCFA-1500 or its electronic equivalent:

 

Item 17: Name of the physician or other practitioner licensed to prescribe the oral anti-cancer drug. 

Item 17A: Unique physician identification number (UPIN) or UPIN "NPP000" for practitioners. 

Item 21 or item 24E: ICD-9 diagnosis cancer code  for which the patient is receiving the drug. 

Item 24D: NDC number for the oral anti-cancer drug (instead of a HCPCS code). 

Item 24F: The charge.

 

Item 24G: Number of units dispensed. Each tablet or capsule is equal to one unit.

 

Item 33: Supplier name and billing number issued by the National Supplier Clearinghouse.

Practices must also be careful when billing office-dispensed antiemetics (drugs used to combat nausea) with oral chemotherapy. In many cases, the antiemetic, normally billed to local Medicare carriers using the appropriate J code, should be billed to the DMERC. According to Medicare regulations, the combinations of oral chemotherapy and oral antiemetics or oral chemotherapy and other antiemetics given in the office should be billed as follows: 

 

Oral chemotherapy drug with oral antiemetic drug.  Submit claims to DMERC for both drugs with the appropriate Q code for oral chemotherapy drugs, Q0163-Q0181.

 

Oral chemotherapy drug with rectal antiemetic drug. Practices should report to DMERC the appropriate code for the oral anti-cancer drug along with K0416 (prescription antiemetic drug, rectal, per 1 mg for use in conjunction with oral anti-cancer drug, not otherwise specified).

Oral chemotherapy drug with intravenous anti-emetic drug. Report the oral chemotherapy drug code to the DMERC, and the intravenous antiemetic drug, such as ondansetron, J2405, to the local carrier. 

 

 

Unlike other drugs billable to a DMERC, approved oral chemotherapy drugs must be submitted with NDC numbers rather than HCPCS codes. However, choosing a reimbursable NDC code opens up several other issues: One drug -- same description, same dosage -- might have three or four different codes. Which do you bill?  That depends on the drug manufacturer. The codes are manufacturer-specific.

Some NDC codes are listed as inactive with certain DMERCs. Which to bill? That depends on the DMERC.

Here are some examples of duplicate codes:

00004-1100-22 Capecitabine, 150 mg, oral, 1 tab per unit 

00004-1100-51 Capecitabine, 150 mg, oral, 1 tab per unit 

00004-1100-13 Capecitabine, 150 mg, oral, 1 tab per unit 

00004-1101-51 Capecitabine, 150 mg, oral, 1 tab per unit 

00004-1101-16 Capecitabine, 150 mg, oral, 1 tab per unit 

00015-0503-01 Cyclophosphamide 50 mg oral 1 tab, per unit
00015-0503-02 Cyclophosphamide 50 mg oral 1 tab, per unit 

 

To ensure payment for oral chemotherapy administration, oncology practices should contact the manufacturer of the drug they're dispensing to obtain the appropriate code. Then, check with their DMERC to make sure the number is still active. If you're not sure which DMERC you should be dealing with, you can obtain a regional list from the Web site www.lmrp.net.