Radiation Oncology Code Capture Challenges
By Susan Vannoni
When physicians mix and match modalities, they are not getting pre-authorizations and they are not getting paid. Take this hypothetical example:
A radiation oncologist performs a consult on a patient with lung cancer and then begins radiation treatment. During the course of therapy for the lung cancer, the patient begins to have neurological problems, so the radiation oncologist orders a diagnostic test to see what’s happening in the patient’s brain. After reviewing the PET, MRI or CT, the patient is found to have brain metastasis. The radiation oncologist now wishes to perform SRS or SBRT to the brain to reduce the neurological symptoms the patient is experiencing—it makes perfect sense clinically to the radiation oncologist to start treatment to the brain simultaneously. Unfortunately, it doesn't make any sense to the payers!
From the payer’s standpoint, the best scenario is for the physician to close out the lung case, summarize the case and then start the brain case. If the radiation oncologist insists on treating the lung and brain simultaneously, the reimbursement is for only one disease site. Since the lung was started first, only the lung case would be the case reimbursed (the brain treatment would not).
The other Radiation oncology code capture problem is what code to use as primary. In this example, the lung case would be listed first on the claim form followed by the brain case.
This will be a real issue with Advanced Payment Models (APMs) with only 17 diagnoses and the episode of care to be determined by the physician’s clinical treatment plan and then at the end of care.
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