Reimbursement for oral chemotherapy can be a losing proposition because Medicare has a long-standing policy against paying physicians for self-administered drugs dispensed in the office. However, a few oral chemotherapy drugs are eligible for reimbursement in this situation. The key to getting paid is knowing which drugs can be administered in the office, which entity you should submit the claim to -- your local carrier or durable medical equipment regional carrier (DMERC) -- and which codes to use, says Elaine Towle, CMPE, practice administrator for New Hampshire
Oncology and Hematology in Hooksett, N.H.
Medicare Covers Some Self-Administered Drugs The Omnibus Budget Reconciliation Act of 1993 authorized Medicare to cover some self-administered anti-cancer pills. These drugs, however, have to contain the same active ingredients as injectable chemotherapy, says the American Society of Clinical Oncology's (ASCO) Public Policy and Practice Department in Alexandria, Va. The drugs in this class Medicare now covers are cyclophosphamide, etoposide, methotrexate and melphalan.
To make matters more confusing, a new class of oral chemotherapy drugs has emerged (called "prodrugs") that do not contain the same active ingredients as injectable chemotherapy -- until they are metabolized. For example, Capecitabine, a prodrug, when metabolized, mimics the continuous infusion of 5-FU (J9190). Thankfully, Medicare has covered prodrugs since January 1999.
In April, the FDA approved a new anti-cancer drug, Gleevec, a once-a-day pill aimed at treating patients with chronic myeloid leukemia (CML) who have not responded to standard therapy. Despite its great promise, the Centers for Medicare and Medicaid Services (CMS, formerly called HCFA) says the drug will not be reimbursed, limiting oncologists to simply prescribing the drug and making patients pay for it ($2,000 to $2,400 per month). This is because CMS considers Gleevec a self-administered drug, a category it normally does not reimburse unless the drug is among the few oral chemotherapy drugs Medicare has approved for coverage in physician offices.
Gleevec's exclusion should not discourage oncologists from seeking reimbursement for other oral anti-cancer drugs they dispense to their Medicare patients. Capecitabine for example, is covered by Medicare. A major caveat for reimbursement is that if oncology practices dispense a drug in the office they must file the claim with their DMERC, using the appropriate national drug code (NDC).
How To Bill Your DMERC for Reimbursement Many oncology practices have avoided billing their DMERC because of the red tape involved in getting a provider number and payment delays. "But with oral chemotherapy drugs in the pipeline, I think we all need to figure out a way to deal with the DMERCs," Towle says.
Practices must submit claims for approved oral anti-cancer drugs and prodrugs to a DMERC on form HCFA-1500 or its electronic equivalent. However, you can't [...]
