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Medical Coding News Archives

OIG Finds Chemotherapy Billing Still Problematic

 
June 20, 2013:

Regina Magnani, RHIT, Clinical/Technical Editor

In its Semiannual Report to Congress for October 2012–March 2013, the Office of Inspector General (OIG) noted three continuing issues related to chemotherapy.

The OIG found numerous instances in which Medicare payment was incorrect for the drug trastuzumab (Herceptin), used to treat breast cancer. Medicare will pay for the amount of a discarded drug in a single-use vial or package if a provider must discard the remainder after administering a dose or quantity of the drug or biological. However, this rule does not apply to multiuse vials, such as those used for supplying trastuzumab. (See the Medicare Claims Processing Manual, Pub. 100-04, chap. 17, sec. 40). Some providers reported incorrect units of service on line items with unit counts that represented full multiuse vials. Contractors did not detect these errors, and payments were made for the full multiuse vial.

The second issue involves the oral form of aprepitant (Emend), which is payable as an outpatient service under Medicare Part B if providers administer or prescribe a three-drug oral regimen, along with at least one of nine specified anticancer chemotherapeutic agents. The OIG found that 91 percent of the claims for aprepitant billed by five providers were incorrect in that they did not reflect the coverage requirements.

Coverage requirements as detailed in the Medicare Claims Processing Manual, Pub. 100-04, chap. 17, sec. 80.2—80.2.4, state that for the oral form of an antiemetic drug to be payable as an outpatient service under Medicare Part B, providers must administer or prescribe a three-drug oral regimen, along with at least one of nine specified anticancer chemotherapeutic agents. The oral three-drug combination is aprepitant, dexamethasone, and a 5-HT3 antagonist, such as granisetron, ondansetron, or dolasetron.

The oral three-drug combination is considered reasonable and necessary for only those patients who are receiving one or more of the following chemotherapeutic agents:

  • Carmustine
  • Cisplatin
  • Cyclophosphamide
  • Dacarbazine
  • Mechlorethamine
  • Streptozocin
  • Doxorubicin
  • Epirubicin
  • Lomustine

The oral antiemetic regimen is reported with the HCPCS Level II codes under revenue code 0636 on the same claim form. Line-item dates of service, as well as a cancer diagnosis, must be reported.

The third issue is a recommendation that CMS consider seeking legislative authority to implement least-costly-alternative (LCA) policies for Part B drugs under appropriate circumstances. Between 1995 and 2010, luteinizing hormone-releasing hormone (LHRH) agonists used to treat prostate cancer were covered under Medicare Part B subject to LCA policies. LCA policies based the payment amount for a group of clinically comparable products on the least costly one. In April 2010, LCA policies for Part B drugs were discontinued in response to a court ruling stating that the use of an LCA policy was not authorized under Medicare law.

If LCA policies for LHRH agonists had remained in place, Medicare expenditures would have been reduced by $33.3 million over one year, from $264.6 million to $231.3 million. After LCA policies were discontinued, utilization patterns shifted dramatically in favor of certain costlier products, even though the overall use of LHRH agonists to treat prostate cancer has been decreasing.

 

 
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