Oncology & Hematology Coding Alert

Use these expert tips to avoid making the same mistakes these practices made.

According to Medicare’s Physician Compare data, there are about 12,000 medical oncology/hematology physicians in the US — and considering that this specialty billed almost $118 million improperly in 2016, that averages out to suggest that each doctor was responsible for some $10,000 in errors.

Background:  The Centers for Medicare and Medicaid Services (CMS) released its “Appendices for the Medicare Fee-for-Service 2016 Improper Payments Report” in December as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the most egregious errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found an 11.7 percent improper payment rate among Part B claims during 2016, with the vast majority of those being classified as overpayments to providers.

The majority of Part B errors were categorized as such due to insufficient documentation (totaling $5.5 billion in errors), while incorrect coding was also a major error source (costing $2.7 billion in errors). Medical necessity and missing documentation errors were also seen identified among Part B claims. When it came to oncology, the results were not all positive, with many oncology services registering high error rates.

Oncology Services Logged Millions in Part B Errors

When the government scrutinized oncology and hematology procedures, the CERT auditors found that the hematology/oncology specialty had a 3.9 percent error rate, logging $117.9 million in projected improper Part B claims and medical oncology had a 9.2 percent error rate, totaling $118 million in improper payments. Among the most common errors within the specialty were the following:

Know How to Avoid These Issues

Historically, when CMS finds error rates as high as these, Medicare Administrative Contractors (MACs) will request recoupment from the practices overpaid in error.

Here’s why: “If the insurer became aware that a practice coded incorrectly or maintained insufficient documentation to support their claims, that will lead them to recoup reimbursement from the practices that billed improperly, since the practices didn’t meet the criteria to have earned that reimbursement,” says healthcare consultant Terri Orcala of Orcala Billing in Kansas City, Mo.

Consider the following examples of improperly-coded oncology claims so you can avoid a slot in CMS’ next improper payment report.

Example 1:  You report 77427 (Radiation treatment management, 5 treatments) for a week of radiation treatment management services. The patient’s record includes only the following: Documentation of six treatments over the course of eight non-consecutive days, chemotherapy records, notes from each treatment session, CT results, and lab results.

Is this coded properly? The notes would typically support reporting 77427, and the coder is correct in reporting one unit of the code for the six treatments. Although the descriptor refers to five treatments, CPT specifically says that “one or two fractions beyond a multiple of five at the end of a course of treatment are not reported separately,” so the sixth session is covered in the reporting of 77427. In addition, it isn’t a problem that the six visits took place over eight non-consecutive days, because CPT also states, “the services need not be furnished on consecutive days.”

The problem, however, is that the patient’s record did not include the radiation treatment plan or the physician orders for it. CGS Medicare published a case study for a similar situation where these items were missing. The payer stated, “The service was denied for insufficient documentation to support the billed service.” You must maintain all the required supporting documents to avoid being found to have insufficient documentation resulting in a request for recoupment of monies paid in error.

In this example, the practice would likely have to return the $189 it received for 77427 due to the missing documentation required to be in the patient’s medical record.

Example 2: The practice creates a treatment plan for a patient’s cancer case, and the therapy course includes brachytherapy and external beam therapy. The practice reports two units of 77263 (Therapeutic radiology treatment planning; complex) on separate lines of the claim, with modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) appended to the second line item.

Do you see the problem with this chart?  The practice was on the right track in reporting 77263, but it should have only billed one unit of the code. “Billing multiple treatment plans for a single course of treatment is not considered reasonable or necessary,” according to the Mountain State Blue Cross Blue Shield policy. Additionally, the CMS Medically Unlikely Edit (MUE) for this code is one (1), meaning only one (1) of these services is reimbursable. Typically, payers will only reimburse a second reporting of 77263 in cases when the patient’s condition changes and a new treatment plan must be created. In addition, CPT specifically says that complex radiology treatment planning covers a “combination of therapeutic modalities,” such as the orders for brachytherapy and external beam in this case.

Therefore, if the use of modifier 76 in this case does allow the practice to bypass the medically unlikely edit (MUE) of “1” inherent to 77263, the patient may have to return the $169 allowed for the second line item if it collects for both. The same would be true if the practice appended modifier GD (Units of service exceeds medically unlikely edit value and represents reasonable and necessary services) instead of 76 — the claim might be paid, but if an auditor later reviewed the documentation, the practice would face paybacks.

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/AppendicesMedicareFee-for-Service2016ImproperPaymentsReport.pdf.