Oncology & Hematology Coding Alert

Question: We've been getting conflicting information on reporting oral Emend for patients when our office supplies the drug. Are we allowed to bill Part B or not?

Maryland Subscriber

Answer: You aren't the only one with questions -- CMS recently released an MLN Matters article aimed at clearing the confusion on when you may include Emend (J8501, Aprepitant, oral, 5mg) on a Part B claim.

Rule: "CMS provides Part B reimbursement for oral anti-emetic drugs when used as a full therapeutic replacement for intravenous dosage forms as part of a cancer chemotherapeutic regimen, when the drugs are administered or prescribed by a physician for use immediately before, at, or within 48 hours after the time of administration of the chemotherapeutic agent," the article states

(www.cms.hhs.gov/MLNMattersArticles/downloads/SE0910.pdf).

Application: Part B covers oral Emend when the oncologist prescribes it for "days 1-3 of the oral anti-emetic 3-drug combination of Emend, a 5-HT3 antagonist, and dexamethasone. This regimen acts as a full replacement for IV anti-emetic therapy."

The patient receives the first oral dose around the time of chemotherapy administration, the second within 24 hours, and the third within 48 hours of treatment.

Key: Don't miss these two requirements stressed in the article:

1. "The physician must indicate on the prescription that the beneficiary is receiving the oral anti-emetic drug as full therapeutic replacement for an intravenous anti-emetic drug as part of a cancer chemotherapeutic  regimen in order for the beneficiary to receive coverage under Part B."

2. You must include all three drugs in the combination regimen on the same claim for Part B reimbursement.

If the patient instead receives intravenous Emend on the treatment day and takes oral Emend on days two and three, only bill the IV Emend under Part B. The oral Emend would be eligible for payment under Part D in this scenario.