Oncology & Hematology Coding Alert

Tap these resources on Medicare's oral anti-emetic policy.

If your practice reports oral anti-emetics, be sure you're up on the latest ondansetron coding news or you could start seeing denials.

This drug received a new HCPCS code, effective Jan. 1, 2012: Q0162 (Ondansetron 1 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen).

To make room for this new code, HCPCS deleted Q0179 (Ondansetron hydrochloride 8 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen), says Janae Ballard, CPC, CPC-H, CPMA, CEMC, PCS, FCS, coding manager for The Coding Source.

Bottom line: Reporting Q0179 for a 2012 date will bring an instant denial. You should use Q0162 instead.

Zuplenz Factors Into Unit Change

Pay attention to how the code change affects unit reporting, Ballard says. For 2011's Q0179, one unit represented 8 mg. In 2012, one unit of Q0162 represents only 1 mg.

The change allows for more accurate reporting of the ondansetron oral soluble films sold as Zuplenz. The films are available in 4 mg and 8 mg doses. Although codes specific to the oral films were requested, the new code was crafted so that it could "be assigned to any oral dose form available," states the May 17, 2011, HCPCS Public Meeting Agenda (www.cms.gov/MedHCPCSGenInfo/downloads/Tues_May17thDrug-Agenda.pdf).

Brush Up on Oral Anti-Emetic Rules

Before reporting Q0162, take heed. "There is a specific set of guidelines for oral anti-emetics to be considered payable by Medicare," says Lisa S. Martin, CPC, CIMC, CPC-I, chargemaster specialist for OSF Healthcare System in Peoria, Ill.

Smart idea: Review Medicare's national resources on reporting oral anti-emetics. Take a look at Medicare Claims Processing Manual (MCPM), chapter 17, section 80.2 (www.cms.gov/manuals/downloads/clm104c17.pdf) and Medicare Benefit Policy Manual (MBPM), chapter 15, section 50.5.4 (www.cms.gov/manuals/Downloads/bp102c15.pdf).

Claims processing jurisdiction is one crucial area covered in the MCPM. Practices should bill the oral anti-emetic to their Durable Medical Equipment Medicare Administrative Contractor (DME MAC), Martin says. In contrast, you'd report an intravenous anti-emetic to your local carrier (Part B MAC).

Another important requirement is that the "physician must indicate on the prescription that the beneficiary is receiving the oral anti-emetic drug(s) as full therapeutic replacement for an intravenous anti-emetic drug as part of a cancer chemotherapeutic regimen," the MCPM states. "Full therapeutic replacement" means the oral anti-emetic "cannot be given as a supplement to an IV -- it must be a complete therapeutic substitute for the IV anti-emetics," says Martin.

Read on: For Medicare patients, you also should check for local coverage determinations (LCDs) that address coverage for oral anti-emetics by the appropriate region's DME MAC, says Martin.

The LCD may reveal specific modifiers you should use with the drug code, Martin says. For example, modifier KX (Requirements specified in the medical policy have been met) may apply.

Additionally, to support oral anti-emetic coverage, the patient "must be receiving what is considered to be a highly emetic chemotherapy agent, such as Cisplatin or other drugs listed on the DME MAC's LCD," says Martin. (The MCPM provides a list of the chemotherapy agents that support necessity for the oral anti-emetic tri-pack of aprepitant [Emend], a 5-HT3 antagonist [such as ondansetron], and dexamethasone.)

Don't miss: "Commercial insurances also may have completely different payment policies for oral medications," Martin says. Verify the payer policy "to see how or even if these would be paid under the patient's medical benefits."