Oncology specialists deal with diagnosing and treating cancer. Cancers are serious body ailments that completely disturb the function of the organ involved. Cancers start affecting surrounding tissues and other organ systems when they are malignant and progressive. To limit the spread of cancer and avoid deadly situations, oncology consultation is very important and timely. It is a very serious and complicated disease and needs good medical experts to deal with the cancer situation. There are CPT codes defined for oncology consultation sessions, and these codes hold significant importance in billing services provided to cancer patients during consultation sessions.
In this article, we will discuss the various types of CPT code for oncology consultation and their billing guidelines. We will also learn the importance of documentation and use of modifiers while billing for surgical oncology CPT codes.
Understanding of CPT Codes for oncology Consultation
CPT codes were introduced by the American Medical Association (AMA) in the 1960s with the aim of standardizing the medical services rendered to the patients. CPT codes serve as a common language among healthcare professionals, players and patients. Each CPT code represents a unique medical service like office visits, surgical procedures, medical procedures or counselling etc.
Among the CPT codes, there are oncology billing codes in chapter 9, which represent the oncology services provided to patients. These codes are necessary to bill insurance companies adequately. There are oncology consultation, treatment, and management codes. There are a variety of consultation codes that bill for oncology consultation. They start from 99241 to 99245 for office visits and 99251 to 99255 for inpatient consultations. Each code is specified by unique medical services and time duration. The variety, number of services, documentation requirements, and billing guidelines vary for each oncology consultation code.
Types of Oncology Consultation & Relevant Codes
1. Initial Consultation
Patients visit for initial consultation after having cancer symptoms. CPT codes 99241 to 99245 are used to bill the initial visits. These visits include in-depth discussions about the ailment, diagnosis criteria, staging, and treatment plan. It is also important for the healthcare professional to tell the patient the prognosis of the situation. Each consultation code bills different scenarios, such as 99241, which is used to bill the 15-minute session in which straightforward decisions are made. While 99245 is used to bill 80-minute sessions. Complex severity of cases is discussed, and difficult decisions are made during these visits. Oncology CPT codes, including 99251 to 99255, are used to bill the same services as 99241 to 99245, but the only difference is inpatient services. 99251 to 99255 are used for oncology consultations with admitted patients in the hospital.
2. Follow-Up Consultation
99231 to 99233 oncology billing codes specify follow-up consultation which is provided on and off to the cancer patients. Lab reports, outcome of treatment, therapy plans are discussed during these visits. These codes differ from each other depending on the time duration and complexity of the situation. Follow-up sessions have a low reimbursement rate rather than initial visits considering less time intervals and no in-depth discussion.
3. Telehealth Consultation
The Covid pandemic has made telehealth important to the world as a safe and infection-free consultation environment. Oncology patients are already immunocompromised, and it is very dangerous for them to visit infectious places like hospitals and clinics. They can get consultations using telehealth services, and CPT codes should be there to bill for these services. Oncologists and patients come into one-to-one meetings and discuss things. General evaluation and management codes (99201-99215), along with modifier 95, are used to bill for telehealth consultation services. Modifier 95 allows payers to understand that medical consultation is provided through telehealth.
Modifiers Used For Oncology Billing
If other medical services are provided along with the main CPT code billed services, then the use of modifiers is necessary for complete understanding. Modifiers can not be used alone or billed separately for reimbursement. They always come with main CPT codes to elaborate additional services or any other intervention. There are two modifiers which are used by oncologists:
- Modifier 25: It is used in the medical bills when another separate procedure is done by the oncologists in addition to consultation. I.e, if a minor procedure is performed during a consultation visit then, modifier 25 is used.
- Modifier 95: This modifier elaborates that consultation is given to the remote patient using the Telehealth service.
Other Relevant Oncology Medical Billing Codes
Besides consultation codes, there are many other oncology codes related to treatment, surgical procedures, diagnostic procedures, radiotherapy and chemotherapy. It is recommended for healthcare professionals to know about these codes for undergoing error-free billing and coding processes.
Biopsy Procedure
Biopsy is done as a primary diagnostic procedure to make the correct diagnosis. Biopsy is defined as taking tissue samples from the suspicious mass in a body. It is checked by a pathologist to give a report about the mass. Biopsy helps to know the benign or malignant nature of the cancer. There are many surgical oncology CPT codes for biopsy procedures.
For skin biopsy, CPT codes 11102-11107 are used. In this procedure, shaving, clearance, and excision of the part of tissue is taken. It is used to check skin cancers, and the findings are documented.
Another biopsy method is fine needle aspiration (FNAc), billed by 10021 and 10022. It is a less invasive method in which a needle is pricked into the suspicious mass to take some of the internal tissue. It is also evaluated for the nature of cancer.
Breast cancer is the leading cause of death among women, and it is important to check for breast cancer periodically after menopause or if genetic associations. Biopsy is taken from breast tissue using assisted vacuum techniques or needle aspiration method. Such kinds of biopsies are billed by 19081-19126 oncology codes.
Tumor / Lesion Excision
Abnormal lesion or tumour is excised whether it is malignant or benign in order to terminate its spread and progression to the surrounding tissues and organs. There are CPT codes 11400-11446 cover the benign tumour excision like lipoma or any skin growth. Documentation includes the site and size of tumour and the technique used for excision.
If the cancer is malignant then, other codes including 11600-11646 are used in the medical bills. Malignant billing codes are reimbursed higher due to the complexity of the procedure.
Radiotherapy CPT Codes
There are some cancers that need radiotherapy for their termination or limitation. Radiotherapy is also given post-operatively to kill the cancerous cells if remaining. 77470 is the major radiotherapy code which involves a complete evaluation of the patient’s situation and rendering of radiotherapy. Risk factors like immunocompromised and older patients should be excluded before radiotherapy. If risk factors are present, then therapy sessions are adjusted accordingly.
Oncology Billing & Coding Considerations
Healthcare professionals should pay special attention to the medical billing rules and regulations to gain a proper understanding of the process. This helps them to reduce the denial rate and increase potential revenue, which can be used for the welfare of the healthcare organization. A few billing considerations should be in mind while billing for oncology codes:
Documentation Requirement
Documentation is the key indicator for a successful billing process, and there is a strong need to maintain it if you want to grow financially. Documentation helps to reduce denial rates and undergo external and internal audits. Many payers ask for documentation details along with medical bills to check compliance. For oncology consultation visits, it is recommended to get the patient’s history first. Personal history and insurance coverage should be documented. Detailed medical history of the symptoms with which the patient presents, previous diagnosis of the disease, and family history should be known and documented.
Potential findings from the medical examination should be noted. Both objective and subjective notes can help in the documentation process. After making a diagnosis, details about the decision-making and management plans should be noted and kept as medical records.
Oncology Codes Reimbursement
Every single oncology code has different reimbursement requirements and rates depending on the complexity of medical services covered by them. Reimbursement rates also depend on many factors like geographical location, relative value units and type of payers. Private insurance companies have higher reimbursement rates than the government plans including Medicare and Medicaid. Relative value units affect the rate as much as these units help to quantify the value of each service, expertise of oncologist, clinic location, practice expenses and liability costs.
Reimbursement rates also vary from one location to another as rates are defined according to the living cost of that geographical location. Oncologists should understand and read all rules and regulations before stepping into the field of medical billing and coding.
Best Practice Tips
For effective and error-free medical billing, there are a few tips that healthcare professionals can follow. Every healthcare organization has billing experts who manage medical bills and reimbursement cycles. Billing policies are updated periodically to make the process over-efficient, and for that reason, billing experts need to review and understand new policies. If your organization is facing a higher denial rate and you don’t know the errors behind claim denials, then you can hire a third party with good expertise. Third parties have experts with vast billing knowledge and experience. They can help you to reduce the denial rate and increase revenue generation.
There are many billing software in the market now which helps to streamline and automate the billing system. Billing software linked to artificial intelligence can help to detect mistakes in the process while billing and rectify them. So, there remains very less chances of objectionable claim submission.
Conclusion
Oncology is the study of cancer, and oncologists deal with diagnosing and treating such conditions. Cancer is a very serious ailment, and it becomes life-threatening if left untreated. Patients visit the oncologists for diagnosis and management plans for their disease. The services provided by the oncologists in the office or inpatient visits are billed by some specific oncology medical billing codes.
There are three types of consultation, i.e., initial consultation, follow-up consultation, and telehealth consultation. Initial consultation sessions last for 15 to 80 minutes, depending on the severity of the disease, and these visits are billed by 99241-99245 for office visits and 99251-99255 for inpatient visits. Similarly, there are many other oncology codes that bill for follow-up sessions.
FAQ - People Also Asks
If the procedures concerned with diagnosing or treating cancer are expensive and complex then, many insurance companies have a protocol of prior-authorization. This protocol should be followed otherwise; claims can be rejected.
Yes, cancer screening tests like mammography, colonoscopy, biopsy, and genetic testing are covered by CPT codes. There are separate oncology CPT codes specified for each service, and they should be billed accurately for reimbursement.