Oncology & Hematology Coding Alert

Its not uncommon for an oncology practice to accept bundled payment for chemotherapy services. This includes the costs of the chemotherapy drug, its administration, and intravenous solutions, tubing, start kits and a host of other services the payer wants to include.

Physicians accept this bundled arrangement out of fear of being cut off from patients and/or in exchange for being paid faster by the HMO. The hope is that they can provide a high level of service while not exceeding the amount they will be paid. But oncology practices are finding it increasing difficult to break even in bundled payment situations.

But it doesnt have to be a losing proposition, says Barbara J. Girvin, RN, CCS, CCS-P, president of Medical Management Resources, a Columbia City, IN-based heathcare management firm, whose services include consultation to oncology practices.

Control Costs

The solution lies in the preparation and negotiation of managed care contracts, she says. Girvin advises that oncology practices take the following steps:

1. Know your costs: Too often, physicians enter into managed care contracts without a clear picture of how much it costs them to deliver services. Without that knowledge, its impossible to gauge whether a proposed bundled payment is adequate.

Further, failure to cost out the services included in a proposed bundled payment agreement leaves physicians unable to determine whether the proposed payment takes into consideration all services that can occur for a specific service, such as chemotherapy.

Consider a proposed payment of $220 for one round of intravenous chemotherapy (96408-96414). Included in the payment are the basicsadministration of the agent, nursing time, the chemotherapy agent itself, IV solutions, tubing and start kits. What if the contract includes all other services that might occur as a result of the treatment? For example, the patient might require blood products, such as Epotin Alpha (HCPCS Q0136) to treat anemia, a common side effect of chemotherapy. This expensive drug could easily put the cost of care above the assigned bundled price for chemotherapy treatment.

Girvin advises practices to prepare a worksheet that lists services provided under broader bundled payment categories, such as chemotherapy. For instance, calculate the total for the basic services and supplies listed above and then begin adding the costs of other treatment services.

2. Carve out services you know payment will not cover: As practices begin to assess their costs they will soon learn which items are potentially crippling to their bottom lines. Girvin mentions a few common services that are often unaccounted for but could be included in a bundled payment arrangement:

- Additional hydration for patients who experience chemotherapy-induced vomiting.

- Administration and cost of Zofran to relieve chemotherapy-induced vomiting (HCPCS J2405).

- Additional medication associated with ambulatory pump chemotherapy (CPT 96545)

- Refilling pump (CPT 96520 or 96530)

- Additional nursing time associated with adminis-
tering pump chemotherapy (CPT 96408).

These and other services and supplies identified by oncology practice leaders should be carved out or set aside for payment outside the bundled payment arrangement. This will allow practices to treat their patients without fear of costs grossly exceeding payment. Without a contractual arrangement, however, oncology practices will be hard pressed to convince payers that certain services provided to a patient should be paid outside the bundled payment.

It needs to be spelled out in the contract so that unexpected services dont fall on the shoulders of the practice, Girvin says. Otherwise, payers will be reluctant to reimburse separately for items already included in the bundled payment.

3. Use appeals process: Practices that already are fulfilling the obligations of a contract that includes bundled payments should use the appeals process to extract additional reimbursement to cover unexpected expenses, says Lee Ann Wheeler, billing office manager of Womens Health Specialists, an ob/gyn and oncology practice in Rockville, MD.

We would rather go through the appeals process than just write off the incidental expenses, Wheeler says.

At Womens Health Services, services that are performed in separate areas yet fall under bundled payment are still billed separately. More often than not, a payer rejects the claim, arguing that the separate procedure is part of the bundled payment.

Wheeler then gathers physician notes and other documentation to show that the service is worthy of payment. She then sends this material with a letter to the payer explaining the reasons why the service was necessary and why it falls outside bundled payment. You have to reiterate that the doctor worked on a separate area, Wheeler says.

Procedures that Womens Health Services commonly bills outside bundled payment are ureterolysis (CPT 50715) and lysis of adhesions (CPT 58740). While billing separately for these procedures routinely results in denial of claim, Wheeler says she wins payment on appeal 80 percent of the time.