MLN Matters. . .Information for Medicare Providers |
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Note: This article was revised on March 18, 2008, to add clarifying language in the “Impact to You” section and in the “Background” section. Note: This article was revised on March 13, 2008, to correct the code for Aprepitant to show J8501 in the last paragraph of the “Background” section. All other information remains the same. Provider Types Affected Providers and suppliers submitting claims to Medicare fiscal intermediaries (FI) and/or Part A/B Medicare Administrative Contractors (A/B MAC) for cancer chemotherapeutic services provided to Medicare beneficiaries Provider Action Needed Impact to You This article is based on Change Request (CR) 5655 which clarifies that hospital outpatient departments may bill the entire Tri-Pack of aprepitant, an oral anti-emetic drug given in conjunction w/ two other oral anti-emetic drugs to their FI or A/B MAC as part of a cancer chemotherapeutic regimen that includes the anti-emetic three drug combination. What You Need to Know If the three-drug anti-emetic combination (Aprepitant, a 5-HT3 antagonist (e.g., granisetron, ondansetron, or dolasetron), and Dexamethasone (a cortico-steroid)) is dispensed in a Tri-Pak in a hospital outpatient setting, the Tri-Pak may be billed to the FI as 57 units of J8501 (Aprepitant, 5 mg, Oral). What You Need to Do See the Background and Additional Information sections of this article for further details regarding this issue. Background The Centers for Medicare & Medicaid Services (CMS) states that reimbursement will be provided 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 oral three drug combination is:
Note that oral anti-emetic drug(s) should be prescribed only on a per chemotherapy treatment basis. For example, only enough of the oral anti-emetic(s) for one 24-hour or 48-hour dosage regimen (depending upon the drug) should be prescribed/supplied for each incidence of chemotherapy treatment. The three-drug combination protocol requires the first dose to be administered before, at, or immediately after the time of the anti-cancer chemotherapy administration. The second day, on which only aprepitant is given, is defined as “within 24 hours,” and the third day, on which only aprepitant is given, is defined as “within 48 hours” of the chemotherapy administration. These drugs may be supplied by the physician in the office, by an inpatient or outpatient provider (e.g., hospital, critical access hospital, or skilled nursing facility), or through a supplier, such as a pharmacy. (See the revised Medicare Claims Processing Manual, Chapter 17, Section 80.2 (Oral Anti-Emetic Drugs Used as Full Replacement for Intravenous Anti-Emetic Drugs as Part of a Cancer Chemotherapeutic Regimen which is attached to CR5655.) It has come to the attention of CMS that some Medicare contractors are denying payment for the entire Tri-Pak because two doses of the Tri-Pak (for days two and three) are sent home with the beneficiary. This is a misinterpretation of CR 4301 (Billing for Take Home Drugs; http://www.cms.hhs.gov/Transmittals/Downloads/R882CP.pdf The purpose of CR 5655 is to clarify that hospital outpatient departments may bill the entire Tri-Pack of aprepitant to their FI or A/B MAC as part of the three-drug combination oral anti-emetic. If the three-drug combination is dispensed with a Tri-Pak of aprepitant in a hospital outpatient setting; the entire Tri-Pak may be billed to the FI as 57 units of J8501 (Aprepitant, 5 mg, Oral), and all of the drugs in the three drug combination must be billed in the same claim. This clarification is needed to prevent incorrect denials of claims from hospital outpatient departments for Aprepitant for Chemotherapy-Induced Emesis, as spelled out in the National Coverage Determination (NCD), CR 3831 at http://www.cms.hhs.gov/Transmittals/downloads/R40NCD.pdf CR5655 further instructs that:
All of the drugs must be billed on the same claim. Effective for dates of service April 4, 2005, through December 31, 2007, inclusive, the following HCPCS dispensed by non-OPPS (Outpatient Prospective Payment System) providers qualify the beneficiary to receive the three-drug combination oral anti-emetic: J9050, J9060, J9062, J9070, J9080, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9130, J9140, J9230, J9320, J9000, J9001, and J9178. For the same time period, the following HCPCS dispensed by OPPS providers qualify the beneficiary to receive the three-drug anti-emetic: J9050, J9060, J9070, J9093, J9130, J9230, J9320, J9000, J9001, and J9178. Note that CR5655 instructs your Medicare FI or A/B MAC to adjust denied or partially denied aprepitant (J8501) claims if you bring such claims to the attention of your FI or A/B MAC within six months of the implementation date of January 2008. During this period, the timely filing requirements will be bypassed, as needed, to complete the adjustment. Additional Information The official instruction, CR 5655, issued to your FI and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1281CP.pdf If you have any questions, please contact your FI or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. News Flash - It’s Not Too Late to Give and Get the Flu Shot! In the U.S., the peak of flu season typically occurs anywhere from late December through March; however, flu season can last as late as May. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a one time pneumococcal vaccination. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Don’t Get the Flu. Don’t Give the Flu. Get Vaccinated! Remember - Influenza and pneumococcal vaccinations and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. You and your staff can learn more about Medicare’s coverage of adult immunizations and related provider education resources, by reviewing Special Edition MLN Matters article SE0748 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0748.pdf News Flash - The Hospital Outpatient Prospective Payment System Fact Sheet (revised January 2008), which provides general information about the Hospital Outpatient Prospective Payment System, ambulatory payment classifications, and how payment rates are set, is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network at http://www.cms.hhs.gov/MLNProducts/downloads/HospitalOutpaysysfctsht.pdf Posted: 03/26/2008 |
) which requires billing drugs that are for take home use only to the Durable Medical Equipment Medicare Administrative Contractors (DME MAC). 
