Specialty-focused cancer treatment centers are designed to be extensions of the practices that they serve. If you are part of a urology clinic that has pathology, radiology, and lab services in-house, then you already function as a multispecialty practice. Operating inside a full-service urology practice, radiation oncology is a different kind of service center that is unique because in this setting it is not attached to a hospital and is considered free-standing.
Integrating radiation or medical oncology into the mix can challenge even the most seasoned CEOs, both operationally and financially. Everything from scheduling and tracking cross-specialty referrals to billing audits requires special knowledge and skills unique to cancer care. As the person ultimately responsible, you have two options—recruit and hire someone with this knowledge base or hire a consultant.
Speaking from experience, the best solution might be both. The commitment to hiring a specialist who is dedicated to the practice is a wise choice. However, finding the right person or persons is a different story and is largely dependent upon the market and availability. On the flip side, hiring a consultant who is an expert in the subject matter is also practical, but it can be expensive when services are billed by the hour. In the area of coding, both for compliance and economic reasons, this is one instance where hiring an internal expert and an independent consultant is well-advised.
Your system for billing should include a two-part process, combined with an internal audit mechanism. Because cancer care— and specifically radiation oncology—includes both technical and professional services, documentation of services comes from the electronic generation of billable services produced by the equipment, plus those documented by the providers. A well-trained billing specialist verifies the billing sources using the technical records and electronic health record or paper chart.
Compliant processes include an internal billing audit that occurs monthly, in conjunction with month-end closing procedures, performed by someone other than the cancer center billing specialist. Typically, this is the billing supervisor or manager. I recommend that specialty-focused cancer centers also employ the services of an independent coding expert, as a way of ensuring that correct coding guidelines are being followed. Coding rules are subject to frequent changes, and are often susceptible to interpretation.
When you consider how complex the system is, and how little training physicians get in medical school about coding, it stands to reason that practice leadership must emphasize its importance.
The American Medical Association maintains the nomenclature known as Current Procedural Terminology, or CPT codes. In practice management, it is the sole source of how we define services provided to patients. Our entire business is dependent upon the ability to choose the proper code so that reimbursement from payers and patients alike is accurate and appropriate.
Urologists utilize about 350 codes on average. In fact, most specialists have a procedural repertoire of about 400 codes, out of a universe of nearly 10,000 codes. When you consider how complex the system is, and how little training physicians get in medical school about coding, it stands to reason that practice leadership must emphasize its importance.
This is especially true when urologists establish a new service line, such as cancer care. In particular, radiation therapy is more unique, by coding standards, than people realize. Sequencing and grouping of CPT codes has an impact on compliance and reimbursement. The algorithms should be evaluated annually, if not biannually.
If you use a consultant for expert advice on coding guidelines, be sure to check qualifications thoroughly. Interpretation of coding criteria can be subjective, and may range from conservative to marginal on the compliance scale. Even if you do employ an expert, get a second opinion from time to time. Identify an expert within your practice, and support continuing education for that person. I am always surprised when I learn of practices that do not employ at least one certified coder, particularly in the area of cancer care.
Sometimes I am asked whether it pays to become a coding expert, as a physician, or if it makes better sense to simply hire good help. First, remember that as a physician, you are ultimately responsible for any code you or your practice submits for payment, whether you coded the services or had help. Second, you are the only person who really knows what service was performed. If you document those services thoroughly, then a coder can help tremendously. If you are poor at documentation, then a coder cannot help you. It’s either your risk or your gain.