Part B Insider (Multispecialty) Coding Alert

Published on Sat Nov 11, 2006 PDF

The key: Obtain a DME billing number

Myth: You can't bill Medicare for any oral medications.

Reality: There aren't many oral medications Medicare will cover, but there are actually a handful it will, says Suzan Hvizdash, physician educator for the University of Pittsburgh Physicians Department of Surgery and AAPC National Advisory Board Member.

Medicare will cover immunosuppressive drugs, anti-emetic drugs for chemotherapy patients, and oral chemotherapy medications that have the same active ingredients as infusion chemotherapy, Hvizdash says.

Many oncology billers may be aware that they can bill for oral medications but haven't yet gone through the process of getting set up to bill, says Bobbi Buell, vice president of provider services and reimbursement with P4 in Menlo Park, CA and executive director of the National Cancer Foundation.

The biggest hurdle facing billers is that they don't have a durable medical equipment (DME) billing number, notes Buell. You can't bill for oral medications without obtaining a separate DME number and billing the DME Medicare Administrative Contractors (MACs).

Check your state law: Four or five states prohibit physicians from dispensing oral medications in their offices, says Buell.

If you have a pharmacy in your office, you can bill a -dispensing fee- for oral medications. Medicare introduced two new codes for dispensing oral medications, Q5011 and Q5012, this year.

If you don't have an in-office pharmacy, then you can only bill the DME MAC for the drug itself, using the drug's specific billing code, says Buell. Contact the drug's manufacturer to find out the correct billing number, and make sure Medicare will cover that drug in the doctor's office.

With all of these challenges, many practices are hesitant to bill for oral medications. Southeast Cancer Network in Decatur, AL is considering adding a dispensary to be able to bill the dispensing fee for cancer drugs, says coder Jennifer Rucker. But so far, Southeast Cancer doesn't have a DME number and doesn't bill for any oral drugs.