Oncology & Hematology Coding Alert

Question: When our office files an appeal, we usually think that we should be including more documentation - even if the appeal is successful. What kinds of sources should oncology offices consider when looking for evidence to support an appeal?

New York Subscriber 

Answer: Your office is wise to strive for more documentation in appeals, because it's true: The more information you present in your appeal, the more likely it is that your claim will be accepted upon resubmission.   Appeals should always include supporting documentation for your coding and billing choices, and information from outside sources backing up your claim is also helpful.
 
Insurers are more likely to consider appeals evidence from sources such as:
  the CPT manual
  the ICD-9 manual
  CPT Assistant
  Coder's Desk Reference
  National Correct Coding Initiative edits (even though they technically apply to Medicare, they support your arguments)
  Medicare carriers' local medical review policies (even though they don't bind insurers, they support your arguments) and your national specialty society. 
 
A Few  More: When looking for evidence to support your appeal, you may also want to check out these resources: The Coding Clinic and The Coding Clinic for HCPCS, the Food and Drug Administration's approval list, standard of practice information published by specialty societies (ASCO, ASTRO, ACRO, etc.), and New England Journal of Medicine.
 
When you cite one of these resources in an appeal, include a copy of the page you are referencing with the appeal. As you build your appeal through supporting documentation, try to use specific cases as examples, but deal with the encompassing issue - bundling, E/M requirements, etc. - so the carrier can't deny you on the same type of service again.