Claims Processing Jurisdiction for Oral Anti-Emetic Drugs (Rev. 2931, 07-07-14)

by  Jared Staheli
July 8th, 2015

The following chart shows which drugs are billed to the A/B MAC, or carrier and which drugs are billed to the DME MAC.

Per the Balanced Budget Act of 1997, effective for claims with dates of service on or after January 1, 1998, the claims processing jurisdiction rules in Chart 1 apply. Effective July 1, 2006, claims from institutional (hospital) pharmacies are also billed as shown in this chart.

CHART 1

COMBINATION JURISDICTION
Oral anti-cancer chemotherapy drug with oral anti-emetic drug

DME MAC maintains processing responsibility for the National Drug Code (NDC) oral anti-cancer chemotherapy drug and the K0415 oral anti-emetic drug code combinations.

DME MAC processes the NDC oral anti-cancer chemotherapy drug and Q code oral anti-emetic drug(s) when provided in the physician’s office. Part A MAC processes the 3-drug combination antiemetic (Aprepitant) in the form of a Tri-Pak when dispensed by a hospital.

Part A MAC processes the initial days’ supply of the 3- drug anti-emetic combination when a hospital dispenses it and writes a prescription for the second and third days’ supply.

DME MAC processes the second and third days’ supply of the 3-drug anti-emetic combination.

DME MAC processes the NDC oral anti-cancer chemotherapy drug and/or Q code oral anti-emetic drug(s) when supplied by a pharmacy, including a hospital pharmacy.

Oral anti-cancer chemotherapy drug with rectal anti-emetic drug DME MAC maintains responsibility for processing both the NDC oral anti-cancer chemotherapy drug and the K0416 rectal anti-emetic drug.
Oral anti-cancer chemotherapy drug with intravenous anti-emetic drug DME MAC maintains responsibility for processing the NDC oral anti-cancer chemotherapy drug and the local carrier or Part A MAC for processing the intravenous anti-emetic J code drug(s).
Intravenous anti-cancer chemotherapy drug with oral anti-emetic drug A/B MAC or carrier processes the intravenous J code anti-cancer chemotherapy drug. The oral anti-emetic Q code drug(s) is processed by the DME MAC when provided in the physician’s office, hospital, or when provided by a supplier.
Intravenous anti-cancer chemotherapy drug with intravenous anti-emetic drug A/B MAC or carrier processes both intravenous anticancer chemotherapy J code drug and intravenous antiemetic J code drug(s)

Providers (HIPAA definition) that bill the DME MAC require a supplier number issued by the National Supplier Clearinghouse (NSC) in order to submit claims. Medicare Carriers and Part A MACs should instruct providers without a supplier number to contact the NSC service center at 1-866-238-9652 to request an enrollment package for a supplier number. Alternatively, providers may go to the CMS Web site, cms.hhs.gov/providers/enrollment/default.asp, and download the Form CMS-855-S in Adobe Acrobat format. The application can be completed hard copy and submitted to the NSC.

References:

Claims Processing Jurisdiction for Oral Anti-Emetic Drugs (Rev. 2931, 07-07-14). (2015, July 8). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/claims-processing-jurisdiction-for-oral-anti-emetic-drugs-rev-2931-07-07-14-27119.html

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