More than 1.6 million people are diagnosed with cancer each year in the United States. The growth in the number of people living with cancer is projected to increase from 14.5 million (2014) reaching 18.1 million in 2020. Oncology (surgical, medical, and radiation) is a branch of medicine that deals with the diagnosis and treatment of cancer.
Due to the high figures of cancer diagnosis, it becomes even more important and crucial for oncology practices to have an up-to-date and standardized medical system so that all claims are reimbursed in time and that no inconvenience is caused to the patients who are facing life-threatening diseases. It also contributes directly to revenue targets for a medical practice.
Increased reimbursement equals increased revenues. Moreover, practices spend significant efforts in reworking claims denials to the tune of $15,000 every year in addition to millions of dollars not being paid due to faulty reimbursement processes.
So what does it take to standardize the documentation process, especially with respect to the Oncology specialty?
It needs to be remembered that every step in the process of the oncology practice, needs to be documented either on pre-formatted forms or captured digitally for smooth functioning.
Scheduling of Patient appointment:
Here every visit including the first visit needs to be documented to capture the diagnosis and treatment to be accorded for the right codes to be billed.
Eligibility and Verification:
This is the most crucial part of the first phase- right from the name of the patient to the insurance coverage and what has been covered or not. The patient has to be guided, given that not everyone expects to be diagnosed with cancer, and it’s only after diagnosis does this get established and processed for treatment.
Stringent coding needs to be followed. All notes by the physician need to be reviewed thoroughly and checked when codes are inserted. Laterality should be observed when taking notes or if and when recorded. If transcriptionists are being involved in the process of documentation then every word needs to be transcribed carefully noted when it comes to laterality- anatomy of the body should be thoroughly known when documenting diagnosis and treatment.
Coding classifications is very crucial as it informs about the coder if the primary site has been removed or eradicated and whether that site is currently being treated- the distinction between the primary site of malignancy and any secondary (metastatic) sites
This is very crucial for the claims process. Right from the first-time visits through tests, surgery, treatments, claims to process, and follow-ups, all these phases involve numerous documentations. Following industry standards of documentation is essential not only in medical billing and coding but it also a significant factor to reducing claims denials and having healthy audit outcomes for the growth of the practice or organization. With the healthcare transformation in the recent past from a fee-for-service to a fee-for-value system model, it is essential to follow the best practices in documentation.
Clinical Documentation is not just for administrative purposes but clinical documentation is very critical:
Descriptive and accurate diagnosis along with acuity and severity is essential; linkage and relationship between causal factor is a must; supporting documentation from other specialty is very necessary in certain cases; specifying what was present on admission and what has been ruled out has to be documented with clarity; clarity should be provided when a patient is admitted only for chemotherapy or radiation therapy since these have unique admission codes and the malignancy is not considered the principal diagnosis.
For effective documentation, medical care practice/organization should use
- An efficient electronic health record (EHR) system that is comprehensive enough to include charting, ordering, drug management, recording plan of care, nursing documentation, prescription management, etc.
- Practice Management: All workflows and processes should be automated and centralized for easy checking and auditing purposes
- Outsourcing core processes: You also benefit from consulting an expert medical biller and coder as they provide comprehensive solutions and crucial services like eligibility and benefit verification, preauthorization, electronic and paper claims submission, accounts receivable maintenance, insurance Billing, Insurance follow up, appeal management, denials review, and re-processing.They ensure the usage of the latest billing codes (ICD-10) and modifiers published by CMS(Centers for Medicare and Medicaid Services) to the highest level of specificity so that there are minimal claims denials and drive a sustainable reimbursement process.
- Follow-up Teams: this is essential even if some core processes are outsourced. To ensure the A/R collections are meeting the correct number of days, ensure that claims denied are being appealed and followed up with the right documentation as proofs, as these serve not only for claims denials but even for audits and reports as per the new rules & regulations
Oncology documentation should always ensure that the “medical necessity” is recorded in the EHR as it is one of the common reasons for denials especially given that different payers have different reimbursements coverage. Automation can streamline the overall and detailed documentation process. Standardized billing systems incorporate all the latest codes, modifiers, and insurance policies into their systems so that practices do not have to spend efforts in tracking all codes and policies every time.