How the Business of Oncology Drugs Relates to Meaningful Data For the Medical Oncology Practice (Part III)

Tweet

 

This is Part III of a series. In the previous issue, (Part II), we covered more information regarding “the current state of the oncology business” and the opportunities medical oncologists have. Here is the continuation of that discussion.
What opportunities does the Medical Oncology physician practice have?

Step 1: Unite
What Medical Oncology should be doing now is restructuring their business opportunity. First, the small practices need to unite and deal with the drug purchase industry. Otherwise they will become dinosaurs like the small banks, independent gas stations and food markets. The large practices could care less, and to prove it, everyone knows they still take the lion share of
the drug discounts. The new OHCA or some modification of this can be used to unite and demand that small practices purchase all drugs at ASP or lower. This will guarantee the 6% margin Congress promised medical oncologists.

Step 2: Patient care, defining quality through meaningful use
Next, medical oncologists need to get a reality check on their prime business, which is caring for the patient. Forget the idea of requesting new treatment planning code from the American Medical Association. That will never happen unless new codes are defined for all specialists. That can occur if the specialty of medical oncology embraces the idea of Levels VI thru IX
Evaluation and Management codes. Medical oncology managers and physicians need to pay attention to the “Meaningful Use” idea of defining quality. PQRI has given us the hint of what is to come so now all the private office industry needs to do is define the system, and the practice will be billing more visits and more complicated visits. There are illegal points systems used to score a physician note. What the specialty societies should be doing is creating their own point system that helps define the decision-making part of the note where the meaningful information is identified. Staging the patient, management of the
protocol and disease management are several examples of defining quality. Offer meaningful stories that explain why the physician (with the patient’s approval) chose this therapy over another. Physicians are already doing this. Unfortunately, they are not documenting this.

Step 3: Document, don’t fear the audit
The medical oncology thinking since 1984 has been that that implied outcome should be understood since after all, they are the specialists. Another reason medical oncologists are not coding correctly is they just are scared of the audits (if they bill too many Level V visits). Unity and consistency will take care of this. Neltner Billing has won too many audits for the medical oncologists for them to fear any audits. Consider that the new business of medical oncology includes various types of visits that contain a level of care that can be described in the note. Following this idea of specific categories satisfies the CMS Medicare Learning Network’s MLN Matters number MM6740 that states: “In all cases physicians will bill the available code that most appropriately describes the level of the services provided.”

Step 4-Survive
Below is a list of new medical oncology suggestions that we believe will begin to help our survival and lead to new codes:

1. Consults or new patient visits: always Level V.
   1. First treatment visit: always Level V but lets categorize the visits as such.
   2. First line treatment: one should be a Level IX.
   3. Second line treatment: should be a Level VIII.
2. Third line treatment: Level VII.
3. Fourth line and higher: should be a Level VI unless there was some serious research including phone calls to a physician at a University or other clinical facility seeking information about a new therapy or off-label usage.
4. Restaging a patient: always Level V.
   1. This should be a level higher than a Level V. The Medical Oncology community will have to decide what level of complexity this is.
5. Subsequent visits on day of treatment where the physician amends any part of the order: Level V.
6. Subsequent visits disease progression: Level V.
7. Designing a new treatment plan: Level V.
8. Injection visits with no problems: should be Level III.
9. Injection visits with reported problems: should be a Level IV.
10. Port flush visits where an evaluation occurs increases the level chosen.
11. Follow-up visits post treatment 3, 6: Level IV unless scans and or labs ordered then Level V.
12. Follow-up visits post treatment one year requesting scans and or lab: Level V.
13. First line treatment of any stage of cancer: Level IX.
14. Treatment and care of acute Leukemia and bone marrow transplant patients. Should there be a level much higher than
    1. Level IX? Note, a first line treatment would be considered a Level IX.
15. Second line treatment of any stage of cancer: Level VIII.
16. Third line treatment of any stage of cancer: Level VII.
17. Fourth line treatment of any stage of cancer: Level VI.

Stay Tuned For More Information in Upcoming Issues of The Billing Brief^TM