A Must-Have Guide to Oncology Medical Billing & Coding

Oncology medical billing, not unlike oncology itself, is deeply complex. Patients receive multiple (sometimes repeated) treatments, drug administration is highly precise, and the costs of many oncology drugs are astronomical.

To understand the finer points of medical billing for oncology, billing professionals must zoom in on the unique administrative challenges in this specialty: frequent claim denials, complex coding demands, intensive documentation needs, and more.

Medical revenue cycle management (RCM) for oncology practices demands proficiency with the basics, familiarity with common billing codes, and approaches that address oncology-specific challenges—we’re breaking all of this down in the guide below.

Understanding Oncology Medical Billing Basics🔗

To understand oncology medical billing, you need a basic command of common oncology services, including:

• Chemotherapy
• Radiation
• Immunotherapy
• Surgery
• Hormone therapy
• Stem cell transplantation
• Hyperthermia

In addition, billing associates should understand which entities they’re most likely to bill: Medicare, Medicaid, and commercial insurers are some of the most common parties.

Lastly, the difference between facility billing and professional billing is critical in oncology:

• Facility billing typically includes services offered by institutions—hospitals, surgery centers, rehab facilities, clinics, and private practices.
  
• Professional billing itemizes services provided by individual clinical professionals: physicians (and physician groups), home health aides, laboratories, and durable medical equipment suppliers, for example.

These are the most important concepts to remember for oncology billing associates looking to hone their skills, understand medical billing best practices, and optimize the RCM process.

Common Oncology Medical Billing Codes and Their Applications🔗

Once billing professionals understand the services provided by their practice, they can better identify appropriate billing codes.

Oncology medical billing associates are likely to encounter codes for:

• Chemotherapy administration codes – 96401–96549 series
• Radiation therapy codes – 77401–77499 series
• Drug infusion and injection codes – 96372 (for injection drugs) and 96374 (for IV push)
• Chemotherapy drugs and biologics – J9000–J9999

However, oncology medical billing specialists will also encounter ICD-10 codes: diagnosis codes. Connecting ICD-10 codes to appropriate CPT codes is a must in oncology, and doing so correctly can help prevent billing errors.

ICD-10 codes, like CPT codes, are highly specific. For instance, malignant neoplasms (i.e., tumors) receive ICD-10 codes based on their:

• Histologic behavior
• Location
• Cell type

To ensure accurate billing, the CPT codes used to bill should align with the ICD-10 diagnosis code.

5 Different Medical Billing for Oncology Challenges and How to Overcome Them🔗

With the above in mind, let’s zoom in on five of the most common challenges in medical billing for oncology—the obstacles that can impact a practice’s revenue cycle and the quality of patient care.

#1 Accurate Coding for Complex Drug Administration🔗

Oncology drug administration is complex. One of the nuances of oncology drug billing is coding sequential doses—in other words, accounting for multi-step chemo, immunotherapy, and supportive drugs (like antiemetics or pain relievers).

While there are a few different ways to denote sequential medication doses in oncology, one option is to use the modifier EJ at the end of the code for every dose of a medication after the first. You do not need to use the EJ modifier for the first drug in a series.

It’s also important to note that there isn’t a CPT code for concurrent administration of multiple chemotherapy drugs. Multiple drugs given in the same session are considered to be sequential, not concurrent.

#2 Managing High-Cost Drug Billing and Reimbursement🔗

To ensure proper reimbursement for high-cost drugs, oncology medical billing professionals must prioritize accuracy and detail in billing documentation. All documentation for oncology drug billing should cite:

• The correct J-code for the drug administered
• The units or dosage administered
• National Drug Codes (NDCs) when relevant

To ensure that all of these details are accounted for and correct, double-check billing documentation against clinical documentation. Treatment notes should always list pertinent information, including drug names, dosages, administration method, and more.

#3 Dealing with Pre-Authorization and Documentation Requirements🔗

Increasing the number of “clean claims” in an oncology practice demands special attention to pre-authorization and documentation requirements. To avoid denials and receive full reimbursement, practices will typically need pre-authorization documents for:

• Chemotherapy regimens
• Genetic testing
• Targeted therapies (like monoclonal antibody treatments)

Implementing a pre-authorization standard operating procedure (SOP) and documentation checklist at their practice can help oncology medical billing specialists ensure that all billing documents have been collected prior to submitting a claim.

#4 Handling Medical Necessity and Bundling Edits🔗

Oncology patients often receive multiple services, procedures, or medications during one visit—thus, billing specialists often bill them simultaneously. In an effort to prevent improper payouts, the Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI).

However, before “bundling” multiple services, procedures, or drugs into one claim, billing specialists must ensure that these bills meet NCCI regulations: Not all interventions can be billed together, per NCCI.

Before submitting a claim, review the NCCI tables for both professional and facility services. Doing so will help ensure complete reimbursement and decrease denials.

#5 Avoiding Undercoding and Upcoding Pitfalls🔗

In oncology medical billing, accuracy is a must: Coding too low or too high for services, while tempting in some scenarios, isn’t recommended.

Claims should match treatment documentation to the letter. When in doubt, clarify treatment details with the clinical team to prevent claim denials and ensure accuracy. Undercoding and upcoding can lead to denials and RCM challenges, as well as regulatory and compliance issues.

Compliance and Audit Readiness in Oncology Medical Billing🔗

Oncology medical billing professionals (and medical billing specialists in any discipline) must always be prepared for compliance audits. Practices can improve their audit-readiness (and audit outcomes) by:

• Complying with all payer policies – Submitting claims in accordance with payer policies is a must—especially when it comes to Medicare guidelines. To ensure timely reimbursement, reduce the likelihood of claim denial, and stay in compliance, review policies (and policy updates) carefully.
  
• Maintaining documentation – To avoid fraud allegations, billing departments should maintain high-quality, well-organized patient and billing documentation. Treatment records should be detailed and reviewed for accuracy, and billing documents should match treatments to the letter.
  
• Recognizing common audit triggers – In oncology, common audit triggers include high-dollar claims, excessive Dispense As Written (DAW) claims, and drug mixes. As you might imagine, all of these are realities of oncology; maintaining accurate records and complying with policies can help practices effectively respond to audits if they occur.

Mastering Medical Billing for Oncology Practice Growth🔗

In the face of treatment complexity, oncology medical billing professionals must stay updated on the basics, code and document thoroughly, meet regulatory requirements, and make claim accuracy a top priority.

With ongoing training, billing associates can maintain all of these key skills; increased training can also help billing departments optimize their workflows and improve the claims process for the practice and the patient.

For expert support with medical billing for oncology, turn to Medusind. With our modern, forward-thinking revenue cycle management solutions, your practice can spend more time on the most critical part of medicine: providing exceptional patient care. In fact, we help practices both large and small evaluate and improve their processes every day, including in specialty care areas like oncology.

Learn more about Medusind and how we can unlock the full potential of your oncology revenue cycle.