Advanced Search

Oncology & Hematology Coding Alert

READER QUESTIONS:

Find the Right Trial for Off-Label Payment

Published on Thu May 12, 2005

Question: I heard that Medicare covers the off-label use of colorectal cancer drugs, but my colleagues say Medicare won't reimburse us for those drugs and we shouldn't bother claiming them. Who's right?


Wisconsin Subscriber


Answer: Short answer - if your doctor prescribes the drugs, report them, but whether you'll get paid depends on whether you're enrolled in the proper clinical trials.

On Jan. 28, 2005, CMS announced a National Coverage Determination to cover off-label use of certain drugs - but only in specific National Cancer Institute-sponsored trials that study the drugs' use in colorectal and other types of cancer.

The specific drugs listed in CR 3742 are Oxaliplatin, Irinotecan, Cetuximab, and Bevacizumab. For the specific trials included, head to www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=90.

You'll find the National Coverage Determination at www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp.  

For accuracy, regardless of whether you're in the trial, you should report the drugs your doctor orders and uses.
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in your eNewsletter
  • 6 annual AAPC-approved CEUs*
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more
*CEUs available with select eNewsletters.

Other Articles in this issue of

Oncology & Hematology Coding Alert

View All