Coverage and Billing of Oral Anti-emetics and January 2013 Coverage Updates
A recent OIG audit found that providers did not correctly bill Medicare Part B for the oral form of the drug Emend®. Over 90% of the line items reviewed by the OIG were incorrect because providers did not bill for all of the required drugs in the regimen on the same claim as required.
The coverage of the drug Emend® is described in National Coverage Determination 110.18. Effective for dates of service on and after April 4, 2005, Medicare covers aprepitant (Emend®) to control chemotherapy-induced nausea and vomiting only when:
- Given in combination with a 5-HT3 antagonist and dexamethasone
- Given to patients who are receiving one or more of the following anti-cancer chemotherapeutic agents"
Per guidance in the Medicare Claims Processing Manual, Chapter 17, section 80.2 - “If billed to the FI, all three drugs in the combination oral anti-emetic must be on the same claim.” Also note that the manual instructions state there must be documentation in the patient’s medical record that the oral anti-emetic drug(s) are being given as full therapeutic replacement for an intravenous anti-emetic drug as part of a cancer chemotherapeutic regimen.
Hospitals billing for Emend® should review the coverage and billing requirements to ensure compliance with Medicare guidance.
|New and Revised Coverage Documents published in December include:|
|Medicine: Partial Hospitalization Programs||Cahaba (J10)||LCD||L30008||revised||CPT/HCPCS code updates for 2013||1/1/2013|
|Pathology and Laboratory: Circulating Tumor Cells (CTC) Assays||Cahaba (J10)||LCD||L32293||revised||CPT/HCPCS code updates for 2013||1/1/2013|
|Surgery: Bioengineered Skin Substitutes (BSS) for the Treatment of Diabetic and Venous Stasis Ulcers of the Lower Extremities||Cahaba (J10)||LCD||L31428||revised||CPT/HCPCS code updates for 2013||1/1/2013|
|Molecular Pathology Coding Changes for 2013||Novitas (J12)||Provider Bulletin||NA||new||claim instructions||12/28/2012|
|Radiation Therapy Services||Novitas (J12)||LCD||L27515||revised||new covered diagnosis and other changes||08/01/2012|
|Services That Are Not Reasonable and Necessary||Novitas (J12)||LCD||L31686||revised||12/21/2012|
Polices and articles can be viewed on the Medicare Coverage Database by entering the policy number in the Document ID search.
Article by Debbie Rubio