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 Steps for a Successful Claim

As an 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 must contain the name of the physician or other practitioner licensed to prescribe the oral
cancer drug;

Item 17A must contain the unique physician identi-
fication number (UPIN) for physicians or the
surrogate UPIN NPP000 for practitioners;

Item 21 or item 24E must contain the ICD-9 diagnosis code of cancer for which the patient is receiving the drug;

Item 24D must contain the NDC number for the oral
cancer drug (instead of a HCPCS code);

Item 24F must contain the charge;

Item 24G must contain the number of units
dispensed. Each tablet or capsule is equal to one unit; and

Item 33 must contain the supplier name and billing
number issued by the National Supplier
Clearinghouse.

While Lamar says most practices understand that dispensing oral chemotherapy is not a reimbursable procedure, she nonetheless warns against efforts to use 96549 (unlisted chemotherapy procedure). While dispensing oral chemotherapy is a procedure done in the office, its not a procedure that can be billed for, she says. 96549 was not intended to be a blanket code.

Silver also points out that an oncologist prescribing oral chemotherapy for a patient to pick up at a pharmacy is not entitled to chemotherapy treatment reimbursement. Instead, the claim must be submitted by the dispensing pharmacy. Coverage for anti-cancer drugs also is a Medicare Part B benefit for which Medicare will pay 80 percent of approved charges after beneficiaries have met their annual deductible.

Practices should be careful when dispensing oral-emetics drugs, used to combat nausea, with oral chemotherapy, says Daniel L. Johnson, director with Health Care Consultants of America, an Augusta, Ga.-based coding consulting firm with oncology practice clients. (See Bill Supportive Care Drugs Separate From Chemotherapy to Optimize Reimbursement on page 9 of this issue.)

Johnson says Medicare polices include oral chemotherapy drugs and oral anti-emetics (Q0163-Q0181) under the following conditions:


Coverage is provided for only federal Food and
Drug Administration-approved oral drugs that are
indicated for use as anti-emetics;

The oral anti-emetic must be administered by the
treating physician or in accordance with a written order from the physician as part of chemotherapy;

Oral anti-emetic drugs administered with a particular
chemotherapy treatment must be initiated within two
hours of administration of chemotherapy and must be continued for a period not to exceed 48 hours; and

The oral anti-emetic drug must be a full therapeutic replacement for intravenous anti-emetic drugs that
would otherwise have been used.

Editors note: Supplier billing numbers may be obtained from The National Supplier Clearinghouse, P.O. Box 100142, Columbia, S.C., 29202-3142.

NDC Numbers for Oral Chemotherapy NDC Number, Descriptors 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 00015-0504-01 Cyclophosphamide 25 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 00015-3091-45 Etoposide 50 mg oral 1 tab, per unit 00536-3998-01 Methotrexate 2.5 mg oral 1 tab, per unit 00536-3998-36 Methotrexate 2.5 mg oral 1 tab, per unit 00005-4507-23 Methotrexate 2.5 mg oral 1 tab, per unit 00054-4550-15 Methotrexate 2.5 mg oral 1 tab, per unit 00054-4550-25 Methotrexate 2.5 mg oral 1 tab, per unit 00054-8550-03 Methotrexate 2.5 mg oral 1 tab, per unit 00054-8550-05 Methotrexate 2.5 mg oral 1 tab, per unit 00054-8550-06 Methotrexate 2.5 mg oral 1 tab, per unit 00054-8550-07 Methotrexate 2.5 mg oral 1 tab, per unit 00054-8550-10 Methotrexate 2.5 mg oral 1 tab, per unit 00054-8550-25 Methotrexate 2.5 mg oral 1 tab, per unit 00173-0045-35 Melphalan 2 mg, oral, 1 tab per unit 00182-1539-95 Methotrexate 2.5 mg oral 1 tab, per unit 00555-0572-35 Methotrexate 2.5 mg oral 1 tab, per unit 00555-0572-02 Methotrexate 2.5 mg oral 1 tab, per unit 00555-0572-45 Methotrexate 2.5 mg oral 1 tab, per unit 00555-0572-46 Methotrexate 2.5 mg oral 1 tab, per unit 00555-0572-47 Methotrexate 2.5 mg oral 1 tab, per unit 00555-0572-48 Methotrexate 2.5 mg oral 1 tab, per unit 00555-0572-49 Methotrexate 2.5 mg oral 1 tab, per unit 00677-1610-01 Methotrexate 2.5 mg oral 1 tab, per unit 00781-1076-36 Methotrexate 2.5 mg oral 1 tab, per unit 00781-1076-01 Methotrexate 2.5 mg oral 1 tab, per unit 00182-1539-01 Methotrexate 2.5 mg oral 1 tab, per unit 51432-0522-03* Methotrexate 2.5 mg oral 1 tab, per unit 51432-0522-03 Methotrexate 2.5 mg oral 1 tab, per unit 00904-1749-60 Methotrexate 2.5 mg oral 1 tab, per unit 00378-0014-01 Methotrexate 2.5 mg oral 1 tab, per unit 58469-3998-30* Methotrexate 2.5 mg oral 1 tab, per unit 58469-3998-30 Methotrexate 2.5 mg oral 1 tab, per unit 00603-4499-21 Methotrexate 2.5 mg oral 1 tab, per unit 00364-2499-01 Methotrexate 2.5 mg oral 1 tab, per unit 00364-2499-36 Methotrexate 2.5 mg oral 1 tab, per unit 51079-0670-05 Methotrexate 2.5 mg oral 1 tab, per unit 51079-0670-86* Methotrexate 2.5 mg oral 1 tab, per unit 51079-0670-87* Methotrexate 2.5 mg oral 1 tab, per unit 51079-0670-88* Methotrexate 2.5 mg oral 1 tab, per unit 51079-0670-89* Methotrexate 2.5 mg oral 1 tab, per unit 00405-4643-36* Methotrexate 2.5 mg oral 1 tab, per unit 00405-4643-01* Methotrexate 2.5 mg oral 1 tab, per unit 00904-1749-73 Methotrexate 2.5 mg oral 1 tab, per unit 59911-5874-01 Methotrexate 2.5 mg oral 1 tab, per unit 62701-0940-36 Methotrexate 2.5 mg oral 1 tab, per unit 62701-0940-99 Methotrexate 2.5 mg oral 1 tab, per unit 00081-0045-35 Melphalan 2 mg oral 1 tab, per unit