Radiation Oncology Audit Insights

Are you struggling with your Evaluation and Management reimbursement for Radiation Oncology services? Radiation Oncology has nuances, and you may be leaving money on the table without a good understanding of how the 2021 Evaluation and Management guidelines impact Oncology services.

When capturing Evaluation and Management services, the goal is to capture the true data behind the risk and problems addressed to report the service accurately. Beyond the reimbursement, what else does the accuracy of code capture do?

The Cost of ICD10-CM Data Capture

When it comes to documentation, the goal is to be able to justify the service based on Medical Necessity.

Accurate documentation also allows the insurance to see how to allocate funds for their members based on the risk demonstrated. It is essential to capture the true risk to calculate the resources a patient is expected to consume. In the CMS-HCC Model in risk adjustment, for instance, we do not just capture the primary ICD10-CM code; we capture all diagnoses that shows why that patient is at a higher risk and will contribute to the overall cost of treating them. How can true costs be captured? There is a hierarchy that many diseases can be categorized to that will show the true cost.

Looking first at how diseases are grouped, we can see which combinations will be reported. Having lung cancer will mean you are grouped in HCC 9, and lower hierarchy conditions found in HCC 10, 11, and 12 will not be reported because the cost is reflected in the conditions reported under HCC 9. Perhaps when we look deeper and realize we did not capture the true documented condition and follow the guidelines to report the metastasis and acute leukemia, we missed the true cost of resources the patient will consume.

Category (HCC)
If the Disease Group is Listed in this column……Then  drop the Disease Group(s) listed in this column
8Metastatic Cancer and Acute Leukemia9,10,11,12
9Lung and Other Severe Cancers10,11,12

How Documentation Affects Risk Adjustment Scores

Medicare Advantage plans are concerned that all documented and relevant diagnosis codes are captured before a claim is sent. To account for the cost of patient resources, documentation must support all diagnoses monitored, evaluated, assessed, and treated. It’s important to note the side effects and co-morbidities that affect their risk of treatment but also the risk of mortality.

Barbara Shaw, CPC, CPCO, CDEO, CRC, CEDC a leading expert in CDI, states, “To me, the interesting aspect of oncology auditing is making sure that certain components of the chart are updated and reviewed for each encounter visit with the internal guidelines.

Most visits are at the higher end of E/M levels, and complete chart documentation is necessary. For instance, the nurse and/or medical assistant needs to address with the patient their current use of medications, including chemotherapy and radiation therapy treatments, along with addressing the surgical history as these patients typically have a team of providers and can have procedures between their oncology visits.

I find that being a good “word problem solver” is parallel to a complex patient with primary, secondary, and metastatic cancers. There are many conflicting notes that differ from the oncology timeline to the surgical history to the current note, and being a comprehensive coder and auditor is essential.”

There are significant costs to caring for patients with cancer who have specific comorbidities, which can have a severe impact on the cost of treating them. If we look at the missing documentation in many oncology notes, as well as those from other clinicians, we can see how missing vital code capture impacts the cost.

The Cost of your Medical Decision Making

In many specialties, there are different styles of documentation, and varying Evaluation and Management levels are warranted. In Radiation Oncology, we typically see levels 4 and 5 documented due to the serious nature of the treatment they will receive. These patients are at this point in their treatment because they have a threat to their life or bodily function. This is where our ICD10-CM and Risk of Morbidity/Mortality element of Medical Decision Making comes in.

When interpreting documentation with the 2021 Evaluation and Management Guidelines, the level is based on MDM or Time, but ultimately medical necessity is the overarching factor.

Many times because of the malignancy, metastasis, and additional risks to the particular patient, they will fall into either a Moderate or High level of risk.

To clearly define the risk to meet a Level 5 in the risk area, you will be looking to see the risk to that patient as it relates to metastasis and other comorbidities. With some Cancers, they could be unresectable (pancreatic cancer is an example), which means the surgical oncology step is not available. This will put a patient at a higher risk of mortality without treatment.

Another example is when a patient has primary cancer, the metastasis is clearly seen going to the lymph nodes, which puts them at a high risk of further spreading, and their mortality risk increases. Without a clear connection of identification of these risks or clear documentation of the disease progression, we may only be able to confirm a moderate risk, taking us down to a moderate level 4 without enough data.

2022 vs 2023 cost differences below and how your documentation improvement efforts can impact your revenue

Then there are times when they consider Radiation as a postoperative measure when there is no evidence of cancer, and the risk might be moderate while the problem addressed is now considered low. This will lower your level to level 3 without clear data points being met. How can you protect yourself from the impact?

Audit Protection

You could be missing revenue by choosing the incorrect level. You could also be at an audit risk because if you routinely bill a Level 5, and if you bill a high volume of either level 4 or 5, you are already a target. Understanding the cost variances in choosing the correct level is more critical now than ever with Value-Based Care Models.

Let a seasoned subject matter expert in the Radiation Oncology revenue cycle provide your facility with the added protection of an audit. It’s worth every penny to get it right.

If your facility would like education or a detailed audit of potential missed opportunities, please email Jmcnamara@oncospark.com

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