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Part B Insider (Multispecialty) Coding Alert

ONCOLOGY:

Split Chemo Claims Tear A Hole In Your Reimbursement

Published on Wed Jan 26, 2005 Print Friendly and PDF PDF

Cancer providers need to bill more codes than one claim can handle

A software glitch could be causing delays and costly denials for oncologists.

The problem: At some point during claims processing, carriers' systems are splitting single claims into two or more claims - and this is causing denials and hold-ups. Because oncologists have to bill for new chemotherapy administration codes, drug codes, E/M visits, and the new chemotherapy demonstration project codes, the risk of carriers splitting claims is pretty high, say experts. The split claims are causing trouble in a few ways:

  •  If you bill using a not otherwise classified (NOC) code for a chemotherapy drug, carrier staff will need to process your claim manually to price the drug, explains Andrew Bloschichak, medical director of Part B carrier HGS Administrators.

    And if your initial chemotherapy administration code is on the same claim as the NOC code, it too will be held up. But, if you also bill for a subsequent chemotherapy administration that gets split onto a different claim, it will go forward past manual processing - and result in a denial when the carrier's system sees a subsequent administration code with no initial administration.

  •  Providers must bill three codes (from the G0921 -G0932 series) for the chemotherapy demonstration project, notes Tracy Sweat, a coder with Piedmont Oncology Specialists in Charlotte, NC. Her carrier is rejecting the claims if she doesn't group the three demonstration project codes together on the same claim form.

  •  Some carriers are also rejecting claim forms if the initial chemo administration code isn't on the same claim as the subsequent administration codes, says Roberta Bueller, a San Francisco consultant who works with the Community Oncology Alliance. Even if the codes are on the same date of service, some carriers will reject them if they don't come through the processing system on the same form.

    Due to these problems, payments have been "extremely slow" since the start of the year, complains Kelly Reibman, a coder with Easton, PA oncologist Mariette Austin. She only just started receiving payments for 2005 in mid-February, and the first payments were followed by another dry spell.

    Solution: For five tips to help you conquer split claims, see article later in this issue.

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