As with other specialties, oncology too undergoes recurrent technological and process changes. This affects the entire revenue cycle of this clinically focused specialty; be it in documentation, billing and coding or filing of claims. Hence, apt coding is mandatory to timely collections/reimbursements in an oncology practice.
As per American Society of Clinical Oncology (ASCO), codes not captured at the intended time are a common error in oncology. If this is causing a dwindling of revenues, there are questions which the oncologist must ponder upon. They are:
- Coding: Is the incorrect coding causing issues in claim denials or rejections? Is there a drawback in capturing the CPT (common procedural terminology) codes? Is it possibly under coding or over coding? Is there a mix up or usage of incorrect modifiers? Bone marrow procedures or other transplants/transfusions that require expert coding is unavailable? Are the coders rounding off drug administration times instead of recording the precise time? Are the coders trained and updated in billing and coding rules of the oncology practice? Are the coders aware of the updated codes related to equipment/instrument (e.g. used in radiation oncology) use? Are they aware of the in-patient visit codes or the established office visit codes? Is the physician aware about codes as well? (It is not advisable to depend only on billers and coders to be aware of the codes as they are not a part of the medical decision making process).
- Billing and documentation: Has each step of the procedure been documented well? Are the billers well aware of Medicare and other private insurers’ billing rules and regulations? – They must be updated at regular intervals about the constantly changing Medicare, Medicaid and other private/third party payer’s rules. The Evaluation and Management (E&M) coding rules are specified in the CPT manual, which the billers must understand.
- Patient collections: Is your practice writing down the credit card information in the system and not on Paper and filing it away? Is the collection occurring when the patient visits the hospital at the front desk or does the staff delay the payments by informing the patients that it will be collected once the payments from insurance come in? (The copays need to be captured at the first visit to the hospital). Further, is the staff informing the patients about deductibles upfront? Also, if the patient does not have copay, is the staff helpful in determining any other alternative?
- Plan: Does your oncology practice have a set plan: from verification and validation of demographics and insurance information, collection of copays, deductibles, claim filing, collection from insurance and post visit activity?
The American Medical Association’s (AMA) Relative Value Update Committee (RUC) updates oncology codes on a regular basis. The ASCO also publishes guidelines on oncology’s billing and coding rules. Business reports must be generated quarterly to keep a tab on the health of the oncology practice and to gauge the productivity. The coders must be updated at all times with the appropriate codes and modifiers so that mistakes are avoided. Claims must be filed daily and electronically. The billers and coders must also be aware of new codes instituted by Centers of Medicare and Medicaid Services (CMS). The CPT manual is updated every year with new codes as well as new definitions of old codes. Oncology practices must regularly conduct compliance audits to ensure that the aforementioned questions have been dealt with appropriately and that every patient has been billed for. Drug inventory must be maintained at all times. Aging analysis shows the money owed to the practice which implies that it must be no inefficiencies with respect to bills left unclaimed/denied. Benchmarks must be used to compare performances with other practices.
Careless billing practices can unfavorably affect revenues. It is essential to code accurately, and the earnings billed and collected on time.
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