Oncology & Hematology Coding Alert

Whether you are a new or seasoned coder, you know how important supporting medical documentation, medical necessity, and proper coding are when it comes to submitting clean claims in your oncology practice.

Unfortunately, oncology/hematology logged a 5.6 percent improper payment rate, resulting in over $201 million of projected improper payments. Medical oncology logged a 2.5 percent improper payment rate still resulting in over $88 million of projected improper payments, while radiation oncology logged a 5.7 percent improper payment rate resulting in over $81 million of projected improper payments. This this is according to the CMS’ most recent CERT report released on 12/21/20.

Background: CMS issued the “2020 Medicare Fee-for- Service Supplemental Improper Payment Data” on December 21 as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the biggest errors among Medicare claims and covers the causes of the improperly paid charges. Overall, the government found a 6.3 percent improper payment rate (8.1 percent for Part B) among claims submitted during the 12-month period from July 1, 2018 through June 30, 2019.

Be Aware of Insufficient Documentation

Some of the top mistakes hematology/oncology made that resulted in improper payments included no documentation was reported as a 11.3 percent error rate, insufficient documentation at 77 percent error rate, and incorrect coding at 10.5 percent error rate.

Similarly, radiation oncology’s improper payments included error rates of; no documentation 7.4 percent, insufficient documentation, a whopping 91.5 percent, and incorrect coding was only 1.1 percent.

As for medical oncology, the improper payments included 90.2 percent insufficient documentation, 1.8 percent medical necessity errors, and 8 percent incorrect coding.

CMS identified some of the top causes of insufficient documentation for Part B providers. These include the following:

• The documentation to support the medical necessity was missing or inadequate.
• The documentation to support the services were provided or other documentation required for payment of the code was missing or inadequate.
• The provider’s intent to order or the order was missing.

See Which E/M Codes Featured the Most Errors

CMS breaks down which evaluation and management (E/M) codes had the most incorrect coding errors among all Part B providers, with the following among the biggest offenders:

• Established patient office visits. The outpatient established E/M codes (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …) represented $400.9 million in projected improper payments.
• Initial hospital visits. In the initial hospital visit E/M category (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient …), represented $359.5 million in projected Part B improper payments.
• Subsequent hospital visits. The codes for subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient …) represented $261.6 million in improper payments.
• New patient office visits. Coming in fourth on the list, the new patient E/M codes (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient …) posted $260.6 million in improper payments. (Remember, in 2020, 99201 was a valid code.)
• Hospital visit – critical care. The fifth code series with incorrect coding error involved critical care visits (99291- +99292, Critical care, evaluation and management of the critically ill or critically injured patient …), resulted in a projected $146.1 million in projected improper payments.

As most practices are aware, it’s critical to ensure that you’re reporting your E/M services accurately. Particularly in light of the reimbursement losses that many physicians are facing due to the pandemic, you want to hang on to as much of your income as you can, and correct coding is the best way to do that.

Look out: “It will be interesting to see if these error rates and improper payment projections improve under the new 2021 documentation guidelines in the outpatient / office E/M category compared to the others that will remain under the current 1995/1997 guidelines,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Associate Partner of Pinnacle Enterprise Risk Consulting Services, LLC (“PERCS”), an affiliate of Pinnacle Healthcare Consulting, CO.

Resource: To read the full CERT document, visit www.cms.gov/restricted-access-vbdlvcertreportsdl/2020-medicare-fee-service-supplemental-improper-payment-data.