Coverage and Billing of Oral Anti-emetics and January 2013 Coverage Updates

on Tuesday, 08 January 2013. All News Items | Medicare Coverage

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"
    • Carmustine
    • Cisplatin
    • Cyclophosphamide
    • Dacarbazine
    • Mechlorethamine
    • Streptozocin
    • Doxorubicin
    • Epirubicin
    • Lomustine

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

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

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