(Medicare Claims Processing Manual)

MACs may determine coverage for other all -oral 3 -drug anti -emesis regimens of aprepitant or any other Food and Drug Administration (FDA) approved oral NK -1 antagonist in combination with an oral 5HT3 antagonist and oral dexamethasone with the chemotherapeutic agents listed above, or any other anti -cancer chemotherapeutic agents that are FD - approved and are defined as highly or moderately emetogenic.  See the Medicare NCD Manual, Section 110.18, for detailed coverage requirements.   80.2.1 - HCPCS Codes for Oral Anti-Emetic Drugs  (Rev. 3085, Issued: 10- 03-14, Effective: ICD -10: Upon Implementation of ICD -10; ASC X12: January 1, 2012, Implementation: ICD -10: Upon Implementation of ICD -10; ASC X12: November 4, 2014)   The physician/supplier bills for these drugs with the ASC X12 837 professional claim format, or if approved, with the paper form CMS -1500.  The facility bills with the ASC X12 837 institutional claim format, or if approved, with the paper Form CMS -1450.  T he following HCPCS codes are assigned:    Code  Description  J8501  APREPITANT, oral, 5 mg (Note:  HCPCS code is effective January 1, 2005, but coverage for aprepitant is effective April 4, 2005.  Aprepitant  is only covered in combination with a 5HT3 antagonist, and dexamethasone for beneficiaries who have received one or more of the specified anti -cancer chemotherapeutic agents.)  Q0161  CHLORPROMAZINE HYDROCHLORIDE 5mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0162  ONDANSETRON 1mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0163  DIPHENHYDRAMINE HYDROCHLORIDE, 50mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at time of chemotherapy treatment not to exceed a 48 -hour dosage regimen.  Q0164  PROCHLORPERAZINE MALEATE, 5mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0165  PROCHLORPERAZINE MALEATE, 10mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0166  GRANISETRON HYDROCHLORIDE, 1mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 24 -hour dosage regimen.  Q0167  DRONABINOL2.5mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0168  RONABINO 5mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0169  PROMETHAZINE HYDROCHLORIDE, 12.5mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0170  PROMETHAZINE HYDROCHLORIDE, 25mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Code  Description  Q0171  CHLORPROMAZINE HYDROCHLORIDE, 10mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0172  CHLORPROMAZINE HYDROCHLORIDE, 25mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0173  TRIMETHOBENZAMIDE HYDROCHLORIDE, 250mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0174  THIETHYLPERAZINE MALEATE, 10mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0175  PERPHENAZINE 4mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0176  PERPHENAZINE, 8mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hours dosage regimen.  Q0177  HYDROXYZINE PAMOATE, 25mg, oral, FDA -approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0178  HYDROXYZINE PAMOATE, 50mg, oral, FDA -approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0179  ONDANSETRON mg, oral, FDA -approved prescription anti -emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.  Q0180  DOLASETRON MESYLATE, 100mg, oral, FDA -approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 24 -hour dosage regimen.  Q0181  UNSPECIFIED ORAL DOSAGE FORM, FDA -approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti -emetic at the time of chemotherapy treatment, not to exceed a 48 -hour dosage regimen.   NOTE: The 24- hour maximum drug supply limitation on dispensing, for HCPCS Codes Q0166 and Q0180, has been established to bring the Medicare benefit as it applies to these two therapeutic entities in conformity with the Indications and Usage section of currently FDA -approved product labeling for each affected drug product.   80.2.2 - Claims Processing Jurisdiction for Oral Anti-Emetic Drugs  (Rev. 2931, Issued: 04- 15-14, Effective: 05 -29-13, Implementation: 07- 07-14)  The following chart shows which drugs are billed to the A/B MAC (A) or (B) 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 physicians office.  A/B MAC (A) processes the 3 -drug combination anti -emetic (Aprepitant) in the form of a Tri- Pak when dispensed by a hospital.  A/B MAC (A) 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 A/B MAC (B) or A/B MAC (A) for processing the intravenous anti -emetic J code drug(s).  Intravenous anti -cancer chemotherapy drug with oral anti-emetic drug  A/B MAC (B) 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 physicians office, hospital, or when provided by a supplier.  Intravenous anti -cancer chemotherapy drug with intravenous anti -emetic drug  A/B MAC (B) processes both intravenous anti -cancer chemotherapy J code drug and intravenous anti -emetic 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.  A/B MACs (A) and (B) 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,  http://www.cms.gov/Medicare/Provider -Enrollment -and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html and download the Form CMS -855-S in Adobe Acrobat format.  The application can be completed hard copy and submitted to the NSC.   80.2.3 - MSN Denial /Claim Adjustment and Remark Messages for Anti -Emetic Drugs  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  If the claim for an anti -emetic drug is denied because FDA did not approve it, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 114  RARC: N/A  MSN:  6.2   If the claim for an anti -emetic drug is denied because the drug is not being used as part of an anticancer chemotherapeutic regimen, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 96  RARC: M100  MSN:  6.4  80.2.4 - Billing and Payment Instructions for A/B MACs (A)  (Rev. 3085, Issued: 10- 03-14, Effective: ICD -10: Upon Implementation of ICD -10; ASC X12: January 1, 2012, Implementation: ICD -10: Upon Implementation of ICD -10; ASC X12: November 4, 2014)