Oncology & Hematology Coding Alert

Hint: Zero in on your oncology radiation therapy claims.

Your oncology practice is probably active and bustling every day. However, it’s possible with all the activity, correct coding could be falling through the cracks. Oncology/hematology practices logged a 3.0 percent error rate, which is less than the general Part B population, according to the latest report from CMS—but you shouldn’t rejoice too much. A 3.0 percent error rate translates into over $140 million in projected improper payments.

The backstory: CMS issued its “2018 Medicare Fee-for-Service Supplemental Improper Payment Data” on November 30 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 an 8.1 percent improper payment rate among Part B claims during 2018.

Oncology Visits Still Logged Millions in Part B Errors

On the list of the services with the most Part B improper payments, CMS reports oncology/hematology visits logged a 3.0 percent error rate, totaling over $140 million in improper payments.

The cause might be the following:

• Established office visits had a 66.4 percent incorrect coding error rate and a 24.5 percent insufficient documentation error rate.
• Initial hospital visits had a 66.4 percent incorrect coding error rate and a 30.3 percent insufficient documentation error rate.
• Subsequent hospital visits had a 48.4 percent incorrect coding error rate and a 41.3 percent insufficient documentation error rate.

Major problems: Non-Medicare fee schedule lab tests, non-Medicare fee schedule minor procedures, and the “other specialty” category were all identified as having a 90 percent insufficient documentation rate.

This means you need to be careful to focus on your coding accuracy and supporting documentation.

Radiation Services Got Special Attention

Among the “20 Service Types with the Highest Improper Payment Rates: Part B,” you’ll find “Oncology - radiation therapy.” This improper payment rate got a whopping 10.3 percent. That’s over a $112 million in projected improper payments.

Translation: You need to make certain your radiation therapy claims are in tip-top shape. “For example, when coding therapeutic radiology simulation-aided field setting, be sure your documentation supports the complexity of the simulation code submitted,” says Kristen Taylor, CPC, CHC, Associate Partner, Pinnacle Enterprise Risk Consulting Services, LLC. Per CPT^® guidelines, a complex simulation, 77290 (Therapeutic radiology simulation-aided field setting; complex) must meet the following criteria: “particle, rotation or arc therapy, complex or custom blocking, brachytherapy simulation, hyperthermia probe verification, or any use of contrast material. If a simulation does not meet any of these criteria, the complexity is defined by the number of treatment areas.” Ensure your providers are documenting all steps taken when performing the simulation procedure to make simulation code selection error free.

Avoid These Common Errors

Although many practices may be focusing on the millions of dollars in errors recorded for oncology/hematology, keep in mind not all of them were due to over-coding. Many of the errors involved under-coding and underpayments, which meant these doctors actually deserved more money than they received. Of course, these types of problems are still considered errors and “incorrect coding,” so it would be best to put coding reconciliation checks in place to prevent these issues going forward.

The stats: According to the report, about $13 million of office/outpatient visits were incorrectly paid due to down-coding — in particular, 99212 (Office or other outpatient visit for the evaluation and management of an established patient…) alone had a 22.2 percent underpayment rate.

On the flip side, some $214 million in Part B payments were incorrectly paid due to upcoding errors. In particular, initial hospital visits logged a 15.9 percent overpayment rate.

Incorrect coding: When it came to incorrect coding errors, office and hospital care visits ranked high on the total list of services with these issues. Hit particularly hard were office visit codes 99214 and 99213 and subsequent hospital care code 99233.

Are You Down-coding Office Visits?

With millions in oncology/hematology visits being under-coded — much of it involving 99212 — you may be wondering if your practice makes up part of this number. Check out these quick tips to ensure you aren’t missing compliant and deserved income.

Tip 1: Remember when billing a level 2 established patient service, the provider is focusing on a single issue.

Tip 2: That single issue is minor, or it is following up with the patient regarding conditions either now under control or require no more follow-up.

Tip 3: This level of service is not normally appropriate for evaluating new presenting problems or complex or numerous problems requiring ongoing monitoring.

Tip 4: However, the documentation is essential to support a level of service above what is required for a level 2 visit.

Resource: To read the full CERT document, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2018MedicareFFSSuplementalImproperPaymentData.pdf.