Updated Code Bundling Guidelines for Radiation Oncology Billing

September 15, 2021 by Antonio Arias, MBA, CHBME

Topics: Radiation Oncology

Radiation oncology billing can be a complex experience. Many radiation oncologists struggle with the billing process, including the billing and coding guidelines that ensure a smooth reimbursement process. Besides the complexity, radiation oncologists may feel as if they’re under more scrutiny since their specialty typically affords higher reimbursement rates.

The process involved with radiation oncology billing is only further complicated when new guidelines or regulations are announced. Case in point – effective July 1, 2021, new code bundling guidelines are expected to be followed for radiation oncology practices. We’ve got the highlights here for you to keep you informed of the latest trends and news related to radiation oncology billing. 

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Why Does Accurate Medical Billing Matter for Radiation Oncology Practices?

Accurate medical billing is critical for any health care practice to receive timely reimbursement and low insurance levels, but it is especially essential for radiation oncologists. 

Billing errors can result in delayed reimbursements or denials, which extend the amount of time your radiation oncology practice is paid. Since radiation oncology generally has higher reimbursements per procedure due to the specialty, denials or delayed payments can add up and damage the financial stability of your practice.

If your practice continues to have billing claims denied, your practice’s insurance reimbursements will eventually decline. Denied claims also require time and energy to be contested and resolved. Initially rejected claims can take up to twice the amount of time to process and resolve errors, which reduces the amount of time your radiation oncology practice can spend on delivering care to your patients. 

The majority of radiation oncology patients use Medicare B to assist in paying for their treatments. To have services covered by Medicare, radiation oncologist practices must first be credentialed; after the credentialing process, the practice can bill Medicare for treatments.

While all medical billing needs to be accurate to prevent reimbursement delays and insurance denials, too many denied Medicare or Medicaid claims can result in state and federal regulators conducting an audit on your practice for suspected fraud or abuse. Not only would this result in a damaged reputation for your practice, but it could find you violating the Federal Civil False Claims Act, which carries fines of thousands of dollars per claim. 

By implementing a medical billing and coding process that adheres to radiation oncology billing guidelines, your practice can ensure its efficacy and boost revenue. 

radiation oncology billing

New Radiation Oncology Guidelines for Medical Coding and Billing 

IMRT Treatment Plan Codes

Intensity-Modulated Radiation Therapy (IMRT) is used routinely in the treatment of prostate cancer, head and neck cancers, gastrointestinal and gynecologic cancers, lung cancers, and brain tumors, and more. IMRT is most often used when a tumor partially surrounds or is very close to a healthy part of your body that cannot tolerate the full dose of radiation that is being given to the tumor. 

In line with the American Society for Radiation Oncology (ASTRO), CPT® code 77301, which represents the Intensity-Modulated Radiation Therapy (IMRT), also includes other related radiation therapy services performed as part of the development of the IMRT plan.  

CPT Code 77301 Update

According to the Centers for Medicare and Medicaid Services (CMS), CPT codes 77280, 77285, 77290, 77295, 77306, 77307, 77321, 77331, and 77370 are considered inclusive to code 77301. These codes may not be billed separately if they are performed as part of developing an IMRT treatment plan, whether they are billed on the same or different date of service.

In addition, CPT codes 77280, 77285, 77290, 77295, 77306, 77307, 77321, 77331, and 77370, are not separately reimbursable when performed 30 days prior/after and the day of CPT code 77301 by the same group practice for the same member.

Modifier Codes

Modifier 59 is appropriate to represent a distinct procedural service for a different tumor on a different date of service, and unrelated to the IMRT plan. According to CMS, this modifier is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

radiation oncology medical billing

How Will These New Guidelines Affect Your Radiation Oncology Practice?

There are certain billing and coding guidelines for radiation oncology practices that are unique from other medical specialties. To provide the most efficient medical billing experience and reduce the chances of fines, your radiation oncology practice needs to adhere to them. 

It’s important to remember that treatment planning is a one-time charge per course of therapy. Using oncology CPT codes for multiple treatment plans for a single course of therapy can result in denials. 

For radiation oncology practices to successfully compete in the healthcare industry, an effective medical billing process is essential. By following these medical billing tips, your practice can enjoy the benefits of an efficient reimbursement process. However, many practices find trying to balance radiation oncology billing guidelines with treating patients to be difficult due to the lack of time available to manage the ever-changing insurance billing tasks expected of practices today.

With extra help from professionals who have expertise in radiation oncology billing, your practice can realize faster payments and spend more time delivering care to patients. An experienced medical insurance billing firm like NCG Medical can use their knowledge of both hospital and private practice radiation oncology to help boost your bottom line by identifying missing revenue opportunities and remedying them. Contact them today and transform your radiation oncology practice!

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