Billing is still the primary problem faced by radiation oncologists. It also remains a difficult operation for practices to address, being characterized by few facts, but many assumptions (supplemented by quantities of unfounded rumors, government memoranda, and questionable data). In this respect, at least, billing has changed little over the past year. Nonetheless, new rules and a few surprises from Medicare are having a noticeable effect on billing for radiation oncology.

The Centers for Medicare & Medicaid Services (CMS) increased Medicare payment rates to physicians for 2003. Under the new rule, payments for physician services increased an average of 1.6%, beginning March 1. This increase overrode the 4.4% reduction that had been anticipated for 2003. Each year, the Health Care Financing Administration (now superseded by CMS) establishes the national conversion factor for all of medicine. This conversion factor, calculated in dollars, becomes effective on January 1 of each year, although its adoption for 2003 was delayed until March 1. The relative value units (RVUs) for each CPT procedure are multiplied by the conversion factor to give the reimbursement amount to be paid by CMS. The conversion factor is determined by CMS based in part on the gross national product index, but many other factors are also considered. The resulting total is modified by the local geographic practice-cost index. For 2003, the proposed conversion factor was $34.59, but the final rule set it at $36.7856. For 2001, the conversion factor was $38.2581; for 2002, $36.1992. All medicine uses the same RVU scale and the same conversion factor. Each specialty may adjust its RVUs internally, but must remain value-neutral overall.

Coding practices

The Medicare global period for all brachytherapy procedures is 90 days. Medicare will pay for the first procedure, but will then deny payment for all subsequent procedures because they fall under the global procedure. The modifier -58 for a distinct and different procedural service performed on the same date must be used in coding for subsequent procedures performed before 90 days have elapsed if Medicare is to pay for the additional procedures.

Follow-up codes 99211 through 99215 are no longer subject to a 90-day global period when used with radiation-therapy codes. For 2003, there are no new surgery assistance codes. Some radiation oncologists would like to bill Medicare for the codes shown in the table, but most carriers will not pay a radiation oncologist for these codes in addition to the brachytherapy codes. The Medicare program considers the brachytherapy codes, in general, to include all procedures. The only code usually paid to the radiation oncologist in addition to 77778 is 55859, needle placement (urology) if the urologist does not participate in the procedure (prostate seed implant).

It is estimated that coding errors are responsible for $1.7 billion in improper payments (including both overpayments and underpayments). Most coding errors found by medical reviewers had occurred because the documentation that was submitted by providers actually supported a different reimbursement code than the one that had been used for billing. According to Cancer Care Network, Oklahoma City, audits, the top 10 billing errors are that Current Procedural Terminology (CPT) modifiers are incorrect or missing, diagnosis codes are incorrect or missing, procedure codes are incorrect or missing, the name or identification number of the ordering or referring physician is missing, the place of service indicated is incorrect or missing, the quantity for which the carrier is billed is incorrect, documentation is missing, the date of service is incorrect or missing, the deadline for providing information to the insurer has been missed, and charge capture is incomplete because procedures have been overlooked.

Radiation oncology claims are most often rejected because they contain incorrect International Classification of Diseases, Ninth revision, (ICD-9) codes; CPT codes have been used improperly; nonradiation-related codes have been used; multiple codes have been used for the same case; primary tumors have been  coded as metastases; and code numbers have been truncated.

Nonetheless, coding can be easy for a motivated billing manager. Rules related to proper billing1,2 have been widely published and distributed. Charge capture, unfortunately, is often performed by the least interested personnel in the department. The radiotherapists are too busy to pay close attention to charges. The physics personnel often overreport procedures. The physicians are too busy to worry about billing, and the receptionist has no training in billing. This is why every department needs one or more people to act as designated billing managers. These individuals must be properly trained, well motivated, dedicated to the job, and paid accordingly.

Compliance with Medicare's billing requirements is based on five relatively simple rules. First, document everything. Second, never bill for a procedure if the documentation for it cannot be found in the clinical record. One can bill only for those procedures that are used clinically. Third, always match dates of procedures and billing.

Fourth, never rely on a billing template alone. While templates for billing can be very useful and can improve charge capture, they must be supported by adequate documentation for all procedures. Fifth, score the complexity of each procedure correctly.

The billing process should follow a designated sequence in every case. Once a procedure has been identified, it is captured for billing. Next, the practice documents that the procedure was performed. The primary and secondary insurers are billed. When payment has been received, the account is reconciled.

Patient Privacy

The Health Insurance Portability and Accountability Act (HIPAA) is an unfunded federal mandate that may cost $1,000 per year for the average practice and $50,000 per year for a typical hospital.  HIPAA will have a dramatic impact on the cost of health care, but is likely to produce very little tangible benefit to patients. After October 1, 2003, the 837 claim format will replace the UB92 and HCFA 1500 forms for all submitted claims. The 837 format has 99 service lines in a standard claim, although not all of these lines may be needed or used. Level-III Healthcare Common Procedure Coding System (HCPCS) codes will also be banned, although HCPCS codes from levels I and II will remain in use.

Under HIPAA, a physician practice must have a written policy regarding privacy, must have a HIPAA coordinator, must have a patient privacy officer and committee, must establish a grievance program, and must be aware of civil and federal penalties. A signed consent from the patient to disclose any health information for billing purposes should be on file.

Conclusion

Clearly, the most important thing that a physician must do is to care for his or her patients. The second most important thing is what ultimately makes the ongoing care of those patients possible: billing correctly and effectively for services rendered. n

Carl R. Bogardus, Jr, MD, is president, Cancer Care Network Inc, medical director, Cancer Treatment Center(s) of Oklahoma; and professor emeritus, University of Oklahoma Health Sciences Center, Oklahoma City. This article has been adapted from "Reimbursement Issues in Radiation OncologyA Continuing Saga," which he presented at the Radiology Business Managers Association 2003 Radiology Summit  on May 20, 2003, in San Antonio.

References:

1. American College of Radiology. User's Guide for Radiation Oncology. Reston, Va: ACR; 2001.
2. Cancer Care Network. CCN User's Guide. Oklahoma City: CCN; 2002.