Oncology Billing Services

Medical oncology is billed drug by drug

In medical oncology the drug is usually the largest line on the claim, and the practice has bought it before anyone pays. A billing error here does not cost a visit fee. It costs the drug.

Units come from the code, not the vial

Each drug code describes a fixed amount, such as 10 mg, and the units billed are the dose given divided by that amount. Billing one unit per vial, or rounding the wrong way, is one of the most expensive mistakes in oncology. The NDC, its quantity and its unit of measure go on the claim too, and many payers deny the line when they do not agree with the drug code.

Waste is billed and documented

When part of a single-dose vial is thrown away, Medicare pays for the discarded amount if it is billed on its own line with the JW modifier and recorded in the chart. When nothing is discarded, the JZ modifier says so. Leaving off either one puts the drug line at risk.

Administration follows a hierarchy

Chemotherapy administration, other therapeutic infusions and hydration each have their own codes, and only one service per encounter is billed as the initial one. Everything else is billed as sequential, concurrent or an additional hour. Those choices depend on start and stop times, so an infusion note without times cannot support the add-on codes.

Authorization covers the regimen, not the patient

Payers approve a specific regimen, often down to the specific product. A switch to a different biosimilar, a dose change or an extra cycle can fall outside the approval. We check the authorization against the order before the chair is booked, not after the claim is denied.

A course of radiation is billed in stages

Radiation oncology bills a sequence of distinct services across a treatment course, and the ones that get missed are the planning and management pieces rather than the treatments themselves.

Planning comes in levels

Clinical treatment planning is coded as simple, intermediate or complex, and the level is decided by the number of treatment areas, the dose considerations and the complexity of the volume. Billing every plan at the same level is both a compliance risk and, more often, an under-payment.

Simulation is a separate service, also levelled, and so is basic dosimetry. Intensity modulated planning has its own code and its own documentation expectations, and it is not billed alongside the standard planning code for the same course.

Weekly treatment management

Physician management during a course is billed per block of fractions rather than per visit or per week of the calendar. The requirements are specific: review of the setup films, review of the dose delivered, examination of the patient, and a note recording it. Practices that deliver the care and document it loosely lose these codes on review.

The block is counted in fractions delivered. A week with a machine down or a patient who misses days does not produce a billable block simply because seven days passed.

Image guidance

Image guided delivery is a separate service where it is performed and documented, and it is included in some delivery codes. Which applies depends on the technique billed, so this is checked against the current edits rather than carried over from last year's setup.

Where courses lose money

Two patterns account for most of it. Planning services performed before the authorization was finalized and then never re-billed. And special services, such as a special treatment procedure or special physics consultation, performed for complex cases and never charged because they are not part of the routine template.