Facilities Must Know Oncology APCs and Assess Internal Issues to Appeal Unfair Denials

To improve their bottom line now and ensure that future APC payment rates are set at correct levels, hospital oncology departments must prepare to challenge their local fiscal intermediarys (FI) inappropriate denials for services provided under the outpatient prospective payment system (OPPS).

Confusion about APCs and fear of compliance issues have led many hospitals to undercharge or under-represent the costs of oncology services, according to Mary Lou Bowers, MBA, LCSW, a managing director with ELM Services Inc., an oncology consulting firm in Rockville, Md. HCFA doesnt always get it right, and FIs also deny some services that should be paid, she says. For example, Medicare didnt expect a high volume of oncology visits and procedures to occur on the same day. But that is, in fact, the standard of practice in oncology.

Many oncology services are not procedure-driven; they support the physicians orders and are usually expensive, Bowers notes. A patient in radiation treatment might need skin care or have problems with vomiting or diarrhea and need nutritional help. That represents a cost, yet the radiation department is precluded from showing those visit costs to HCFA because of an edit and a code thats unavailable to hospitals but available for physicians. And, a lot of FIs deny these visits without asking for documentation even though the care precipitated by the radiation treatment is a distinct procedure. Consequently, many hospitals are not billing the visits when they should be, Bowers asserts, because some consultants are advising them to remove from the charge master any items the FIs have denied.

Dealing With New Patient Issues

HCFAs rules for new and established patient visits dont reflect reality, Bowers contends. To use a new patient CPT code, the individual must not have been a patient of the hospital system within the past three years. This is a problem for hospitals because, due to complex delivery systems and the possibility of similar or identical names, its difficult to determine when to apply a new patient code. Some compliance officers, concerned about the risk of fraud, have banned new visit codes.

Bowers says this approach misrepresents the costs of oncology services and that should not be apprehensive about using the new patient codes when appropriate. You could do a supportive education visit for one hour with an established patient who changes treatment, and the resources you use are no different than for a new patient, she says. A lot of oncology service is visit-based, and nurses, social workers, nutritionists and pharmacists provide a great deal of support. Instead of failing to code for such services, Bowers recommends that hospitals appeal unjustified denials.

Note: A HCFA legislative summary dated March 15, 2001 describes [...]

- Published on 2001-05-01