Billing and Coding Guidelines for Radiation Oncology

Radiation oncology or radiation therapy is a medical specialty and an essential part of cancer treatment. The procedure involves damaging the DNA of the cancer cells. It destroys their ability to grow and divide into more and eventually die. The main focus of radiation therapy is to:

• Alleviate the cancer symptoms
• Treat cancer
• Reduce or relieve the pain of cancer patient 

Radiation oncologists are medical specialists dealing with providing radiation therapy. Radiation therapy treatment is introduced in the patient’s cancer treatment plan at some point. Constant improvements are being made in the radiation oncology techniques. Radiology medical billing ensures that the physicians are being reimbursed for the procedures and services they perform. Medical billing for radiation oncology depends on the use of the right CPT codes in medical claims. However, appropriate CPT codes can only be used based on the complexity of treatment and energy levels. This is also why radiation oncology requires accurate documentation and proper medical transcription services. 

Guidelines for Radiation Oncology Billing:

When we talk about radiation therapy billing, medical billing gets quite complex. Incorrect medical billing can result in a claim being denied or rejected by the payer. Accurate and focused medical billing results in faster payments and an improved revenue cycle. Following are some of the guidelines for radiation oncology medical billing and coding:

• E&M services with radiation oncology services are not separately reportable with the exception of the first or initial visit E&M service. This E&M service must be the visit where the decision of performing radiation therapy is made. However, there are some exceptions to this focused medical billing. The initial E&M visit for radiation oncology services may be reported with (some are listed below): 
• Office/outpatient E&M CPT codes 99202-99215
• Initial hospital care E&M CPT codes 99221-99223
• Subsequent hospital care E&M CPT codes 99231-99233
• Observation/inpatient hospital care with same-day admission and discharge E&M CPT codes 99234-99236
• Brachytherapy includes radiation treatment management and continuing medical physics consultation. CPT codes 77427, 77431, and 77336 should not, in general, be reported separately with brachytherapy services.            
• (CPT codes 77750-77790) - Brachytherapy
• (CPT codes 77427 and 77431) - radiation treatment management
• (CPT code 77336) - continuing medical physics consultation                        
• The procedure described by CPT code 77778 requires that a radiation source be applied interstitially. 
•  CPT code 77014 and HCPCS code G6001 should not be reported additionally for guidance for placement of the radiation therapy field for SRS treatment delivery. (SRS - Stereotactic radiosurgery treatment delivery)
• CPT Code 77014 is for Computed tomography guidance for placement of radiation therapy fields.
• HCPCS G6001 code is for Ultrasonic guidance for placement of radiation therapy fields
• Modifier “-59” shall not be used with code 77427 Radiation treatment management, five treatments.  

What is medical billing for radiation therapy?

There are various challenges associated with radiation oncology billing as it can be quite complex. The common challenges faced are with the billing process and the coding guidelines. These challenges can affect the medical billing and reimbursement rate of the healthcare practice. 

Like medical billing for other specialties, radiation oncology billing also comes with several billing errors. These mistakes and errors affect the reimbursement rate and result in claim denials or rejections. This whole process means a higher claim denial rate and delayed or lost payments. Not just this, the claim denials consume a lot of time to process and clear out. However, all of this can be reduced or avoided by the following official guidelines for radiation oncology medical billing (some are listed above).

What are the common reasons behind claim denials?

There are several errors and challenges associated with radiology medical billing. Medical billing errors result in claim denials, therefore, impacting the revenue cycle of the healthcare practice. Reducing these errors is only how the healthcare practice can ensure timely payments and improve the revenue cycle. Following are the common billing errors:

• Inaccurate or incomplete claims:

The most common billing error across various medical specialties is submitting incomplete claims. This can include a missing check box, patient information, or the use of a wrong code. Even a minor digit or alphabet mix-up can change the entire code (miscoding). There can be various coding errors like 

• Duplicate charge
• Incorrect date 
• Entering a few or more digits into the code

All of these coding mistakes or errors can lead to the claim being denied. And therefore, impact the revenue cycle and reimbursements of the healthcare practice. 

• Upcoding and under coding:

These two forms of radiation oncology billing errors are considered unethical and illegal practices. However, under coding and upcoding, medical billing errors can be accidental as well. 

Upcoding refers to the billing practice where the patient is billed for procedures or services that were not actually performed. It includes billing a more expensive procedure than the one actually performed. Upcoding results in higher reimbursements and hence is an illegal act.

On the other hand, under coding refers to when not all the services performed are billed in the medical claim. This unethical practice results in lesser reimbursement. 

• Incomplete or inaccurate patient information:

Incomplete documentation or patient information can result in the claim being denied. Complete and accurate patient information is essential as without it, not only can a claim be rejected, but it is also crucial in case of an audit. Moreover, incomplete or inaccurate patient information leads to errors in medical coding. 

The medical claim must include; 

• The patient’s complete name
• Date of birth
• Gender
• Medical emergency
• The time of the accident
• As well as the patient’s insurance coverage and eligibility.

• Use of incorrect or outdated codes:

Using the correct code and following the coding guidelines is essential for proper medical billing. Medical codes are updated annually; using the incorrect code will lead to claim denials and the payments being delayed. 

How to reduce errors in medical billing?

There are various ways to improve the medical billing and revenue cycle of the radiation oncology practice:

• Complete and correct patient record:

Make sure and verify patient information and keep the information and documentation organized; it is crucial for medical claims. Complete and organized patient data is also critical for claim denials as it comprises the medical necessity behind the procedure(s) performed. 

• Ensure a higher clean claim rate:

Clean claim rate is the rate at which insurance claims have been processed and reimbursed successfully. It is the ratio of how many claims were reimbursed the first time they were submitted. The radiation oncology practice must have a 95% of clean claim rate. Hence, the higher the clean claim rate, the higher the reimbursement rate, faster payments, and improved revenue cycle.

• Avoid code overuse:

Radiation oncology consists of some codes that are “time-sensitive.” These specific codes cannot be used excessively (in case of excessive use, the claim can be denied).

• Ensure timely submissions:

Late submission can also result in the claims being denied or rejected. This is why ensure that medical claims are being submitted within the deadline of the insurance payer. 

Outsourcing Radiation Oncology Billing:

In order to avoid medical coding errors, healthcare practices, physicians and specialties outsource their billing services. Following are some of the benefits of outsourcing radiation oncology medical billing services:

• Reduced coding errors
• Higher clean claim rate
• A team of highly specialized medical billing professionals
• Higher reimbursement rate
• Reduced expenses or fixed costs
• Improved revenue cycle

https://www.cms.gov/files/document/chapter9cptcodes70000-79999final11.pdf