Oncology & Hematology Coding Alert

Question: A couple of our payer contracts are up for renewal soon. Any negotiating tips?

Tennessee Subscriber

Answer: Negotiating with payers can be daunting, but it's a must-do. In a market where reimbursements are declining more often than they are rising, your revenue depends on securing the best rates possible.

First, focus the majority of your efforts on services rather than drugs, advises Ricky Newton, CPA, who spoke about revenue cycle management at the Association of Community Cancer Centers (ACCC) meeting in Richmond, Virginia. Why? "Negotiating drug reimbursement is important but these fees are only going to diminish, which is why focusing on services is extremely important," he says.

Next, narrow your focus even further to those CPT^® codes that you bill out the most. Negotiating better rates on your most-used eight or 10 codes could heavily impact your bottom line for the better. These will vary depending on your site of service, Newton notes, but he generally finds these are:

Infusion Center:

• 96413 - Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug 
• 96415 - Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)  
• 96367 - Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)
• 96372 - Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 
• Hospital evaluation and management (E/M) services 99221-99233, (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components ...)
• Office E/M services 99201 (Office or other outpatient visit for the evaluation and management of a new patient ...) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).