Understanding the Complexities of Radiation Oncology Coding and Billing
For practices and providers, accurate medical billing and coding are essential, regardless of medical specialty. But some specialists, like radiation oncologists, must navigate incredibly complex and complicated challenges to properly document, code, and submit to ensure they are adequately reimbursed for their services. Continue reading this article to learn more about applying the right radiation oncology CPT codes to the claims you submit to ensure you maximize reimbursements for the care you provide.
Making Sense of Radiation Oncology Coding Guidelines
If you perform your coding or have in the past, you know how difficult of a task it can be. What may seem like a little inaccuracy can result in a denied claim and send you back to the drawing board to correct mistakes and resubmit.
There are radiation oncology coding guidelines specific to a variety of services offered, including:
- Consultations
- Follow-up care
- Treatment delivery
- Treatment management
- IMRT treatment planning
- Radiation physics, dosimetry, devices, and special services
Often, CPT codes can and should be bundled when filing a claim. However, there are many instances when they should be billed separately. For a more exhaustive and technical breakdown of radiation oncology CPT codes, you can reference this document provided by the United States government.
Radiation oncology and billing can become specifically complicated when determining which codes are separately reimbursable and which aren’t. It’s complexities like these that require the skilled expertise of coding specialists to ensure claims are properly filed and reimbursements maximized.
Learn more about CPT codes by reading our article about recent updates.
What Are the Most Common Radiation Oncology Coding Errors?
When it comes to claims submissions, everything must be correct. Common mistakes range from misunderstanding requirements to typos. Here are some of the most common radiation oncology billing and coding errors:
- Illegible documentation: It’s a bit of a cliched joke about doctors and sloppy handwriting, but believe it or not, it’s a leading cause of inaccurate coding. When billing and coding specialists can’t decipher notes correctly, errors are bound to happen.
- Haphazard data entry: Whether it’s a chart being filled out quickly during an emergency or a coder feeling rushed at the end of the workday, rushing causes errors.
- Unbundled radiation oncology CPT codes: This happens when a claim is submitted using multiple codes when a single code representing more than the procedure is filed.
- Upcoding services: Upcoding represents using billing codes meant for more complex or expensive procedures than the ones performed.
Incomplete infusion and hydration reporting: Billing for these treatments requires exhaustive documentation for when they started and stopped.
Are you struggling to bill radiation oncology CPT codes effectively and efficiently? Explore our article about how to code more productively.
Why Is Accurate Radiation Oncology Billing and Coding So Important?
Throughout treatment, radiation oncology practices and providers are likely to perform numerous procedures, consultations, diagnoses, and treatments for a patient. In order to be reimbursed appropriately by payers, typically insurance companies, the care documented in a patient’s chart must be translated into universally recognized CPT codes.
While this might seem like a reasonably straightforward task from afar, we assure you it’s not. There are tremendous subtleties and not-so-easy-to-understand distinctions that you must recognize. On the one hand, you may be undercoding services, which could cost you a significant loss in revenue and limit cash flow. On the other, overcoding or applying too many radiation oncology CPT codes can lead to denied claims or payers seeking overpayment returns.
Let’s take a closer look at some of the problems that improper radiation oncology coding can have for providers:
Claim Delays and Denials
The goal of revenue cycle management (RCM) is to keep cash flow steady. RCM is especially important in healthcare because it helps you build a solid financial foundation and focus on quality care rather than tracking down payments. Payers are sure to notice when your radiation oncology coding doesn’t reflect the services provided or representative of the radiation therapy services performed.
Any inaccuracies can cause delays to your reimbursement. Furthermore, it can lead to an outright denial of payment. These problems alone are frustrating enough. But factor in that you have to dedicate the time and resources to make the needed adjustments to ensure accuracy and then resubmit the claim—you’re now looking at a significant period of time. While a single delayed claim might not financially break you or your practice, inaccurate coding is rarely a one-off mistake.
Legal Trouble
Did you know under the Federal Civil False Claims Act (FCA), intent is irrelevant, so even innocent radiation oncology coding can have dire consequences? Any incorrect claims submitted to the government, typically for Medicare or Medicaid purposes, are open to fraud charges.
Again, it’s important to stress that intent does not matter in these cases. So even an innocent mistake can face the same penalties as a more sinister scam (although the harshest penalties would likely require a prolonged display of negligence.) There are several federal, and civil penalties radiation oncology billing and coding errors face, including:
- Fines
- Recovery of up to three times the damages sustained
- Additional fines of up to $22,927 per false claim
- Practice closure
- Imprisonment
What Is the Radiation Oncology Alternative Payment Model?
The Centers for Medicare and Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation put together the Radiation Oncology Alternative Payment Model (RO APM). RO APM allows providers to be compensated a predetermined, site-neutral, bundled rate for most radiation therapy services they provide within a 90-day episode of care.
This advanced alternative payment model eliminates the need to pay for each service individually and incentivizes practices and providers to enhance their quality of care and make their services more efficient. While there are some definite perks to RO APM, many practices also run into challenges, including:
- Difficulties maintaining compliant reporting
- Struggles to develop and integrate new workflows
- Increased costs needed to implement the program
We suggest weighing all your options and studying RO APM to find out if it’s a good fit for your organization.
