Clarification for Billing Part B versus Part D for the Anti-emetic Aprepitant (Emend)
MLN Matters® Number: SE0910
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Provider Types Affected
Providers and suppliers rendering services to beneficiaries with cancer chemotherapy-induced nausea and vomiting (CINV).
Provider Action Needed
This article describes the Centers for Medicare & Medicaid Services (CMS) policy distinguishing Part B versus Part D billing for the anti-emetic medication aprepitant (Emend®) for chemotherapy induced nausea-vomiting (CINV). Be sure your billing
staff is aware of this information.
Issue
How to determine if Part B or Part D should be billed for a drug regimen of aprepitant when used to alleviate chemotherapy induced nausea-vomiting. CMS has received questions with regard to billing aprepitant when used as a complete replacement for intravenous therapy or as a completion of a 48-hour regimen where IV aprepitant is given the day of chemotherapy and the oral medication is given days 2-3 of therapy. This article provides information in response to these questions.
Background
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. Aprepitant (Emend®) is indicated for use as an anti-emetic for CINV when part of a three drug combination regimen.
The three-drug combination is:
- Aprepitant
- A 5-HT3 antagonist (e.g. granisetron, ondansetron, or dolasetron) and
- Dexamethasone (a corticosteroid)
The three drug combination protocol requires the first regimen 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 again 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.
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. Where the drug is provided by a facility, the beneficiary’s medical record maintained by the facility must be documented to reflect 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. All three drugs in the combination oral anti-emetic regimen must be on the same claim to be eligible for Part B reimbursement.
Coverage of Emend Under the Part B Program
Medicare Part B covers Emend when used as part of the following regimen:
- IV Emend provided on day 1 would be covered under B. (Payment for Oral Emend on days 2 and 3 would not be made under Part B but should be billed under Part D.)
- 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 for patients receiving one or more of the following anti-cancer chemotherapeutic agents:
- Carmustine
- Cisplatin
- Cyclophosphamide
- Dacarbazine
- Doxorubicin
- Epirubicin
- Lomustine
- Mechlorethamine
- Streptozocin
Coverage of Emend Under the Part D Program
The Part D program will generally cover Emend when it is not prescribed in accordance with the above Medicare Part B coverage guidelines. If Emend IV is given on Day 1, then oral Emend is given on days 2-3, the oral Emend must be billed to Part D. To assist in billing of Emend, CMS recommends physicians indicate on a prescription that the Emend is being used as part of a CINV chemotherapeutic drug regimen, what day of treatment the patient is on (e.g. Post chemo Day 2) and whether the IV or oral form of the drug was given on Day 1.
Additional Information
Additional information on this issue is available in the MLN Matters article MM 5655 available at
www.cms.hhs.gov/MLNMattersArticles/downloads/MM5655.pdf (PDF, 127 KB).
If you have questions on the proper billing of aprepitant, contact our Provider Contact Center at our toll-free number (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
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. CPT only copyright 2008 American Medical Association.