Staying in Compliance = Smart Business (Radiation Oncology)

CMS requires that the physician documentation supports their charges. In an audit situation, the only guarantee that you have performed a charge (and received payment) is your written documentation. In today’s world of changing reimbursement (i.e., CMS Advanced Payment Model), coding has become (will be even more important in the future) key to getting paid and staying compliant.

Placing a certified coder in the mix at your facility is a great concept. Think about it – a gatekeeper position between your EMR and your billing software that checks your charges against your documentation. This is not to be confused with what some services call coding these days! We are not talking about a person (non-coder) looking at your radiation oncology charges (eyeballing them) against a template; we are talking about certified coders who know radiation oncology and check your charges against the actual documentation in your EMR.

The OIG has suggested that all charges being billed to Medicare be checked for accuracy. Here are a few common red flags:

  • Deviation from treatment protocol standards in the industry and in your geographic area (how many fractions are being delivered and billed)
  • Patient overtreatment for the sake of higher reimbursement
  • Upcoding ICD-10 or CPT codes for the sake of higher reimbursement
  • Ancillary services that do not match the facility’s treatment protocols
  • Supervision issues: treating at more than one facility at a time
  • Using template forms that contain the same language
  • Improper documentation of E&M codes, planning work, weekly patient evaluations, etc.

Examples of Deficient Documentation:

  • Initial and verification simulations were missing documentation supporting physician presence that was distinct to the patient
  • Services (IGRT) billed were not supervised by the billing physician
  • Physics consults and pre-plans lacked medical necessity and/or were never reviewed by a physician
  • Clinical treatment plans were missing documentation for medical necessity
  • Special treatment procedure (77470) lacked patient-specific documentation supporting the extra work required to bill this code

Having a gatekeeper coding person working for you is a Best Practices solution that will not only improve your billing (and maybe your reimbursement) but help keep you in compliance. Think of it as an assurance plan! The small amount you pay for this service pays off in the end in a BIG way. Let Radiation Business Solutions help you, contact us to learn more about our coding services.