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| Oral Antiemetic Drug Billing According to the Oral Antiemetic drug policy article, aprepitant (J8501) and dexamethasone (J8540) are covered only if they are administered with a HT-3 antagonist – i.e., granisetron (Q0166), ondansetron (Q0179), or dolastron (Q0180). When billing, all three drugs must be billed on the same claim. If all three drugs are not billed on the same claim, the aprepitant and dexamethasone will be denied as statutorily noncovered, no benefit category. Granisetron, ondansetron, or dolasetron are eligible for coverage as single agents. The drugs must be administered within 2 hours before or 48 hours after the intravenous chemotherapy drug. Additional quantities of drug, administered beyond 48 hours after the chemotherapy drug will be denied as statutorily noncovered, no benefit category.For aprepitant and dexamethasone, the chemotherapy drug must be one of the following: carmustine, cisplatin, cyclophosphamide, dacarbazine, mechlorethamine, streptozocin, doxorubicin, epirubicin, or lomustine. If not, the aprepitant and dexamethasone will be denied as not medically necessary. The KX modifier may be used with J8501 and J8540 only if one of these intravenous chemotherapy drugs was administered The quantity of drugs dispensed must be limited to a 30 day supply. For aprepitant, the covered quantity for each cycle of chemotherapy is 285 mg, which is 57 units of service of code J8501 (1 UOS = 5 mg)For granisetron (Kytril), the covered quantity for each cycle of chemotherapy is 2 mg, which is 2 units of service of code Q0166 (1 UOS = 1 mg)For ondansetron (Zofran), the covered quantity for each cycle of chemotherapy is 40 mg, which is 5 units of service of code Q0179 (1 UOS = 8 mg)For dolasetron (Anzemet), the covered quantity for each cycle of chemotherapy is 100 mg, which is 1 units of service of code Q0180 (1 UOS = 100 mg)Quantities greater than this amount should not be dispensed at one time unless intravenous chemotherapy administration with one of the chemotherapy drugs listed above is planned more often than once per month For more information please refer to the Oral Antiemetic drugs local coverage determination and policy article on the National Government Services Web site at www.ngsmedicare.com. |
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