[Podcast Episode] How to Pass a Radiation Oncology Audit

When it comes to coding Radiation Oncology services, a thorough knowledge of items like the isodose plan, care-specific guidelines, and the different plans is absolutely crucial. Without mastery, you might fail an audit. And while the word “fail” might induce some anxiety, the good news is there are ways to prepare and pass.

In this podcast, La Tanya says, “One of the biggest things a coder can do when it comes to passing an audit is knowing what to look for. When we talk about the delivery of different radiation modalities, whether or not the writer recommends the patient has a treatment 3D plan versus an IMRT (Intensity Modulated Radiation Therapy) plan versus a 2D plan. Knowing the different plans can be the determining factor in whether or not an audit could pass or fail.”

So how exactly do you ensure accuracy?

Medical coders should know your plan, run reports, and use software to build documentation and procedure checklists. And as an auditor, when you do a final audit with your recommendations, use software. Robust reports help you communicate with the managers and directors more effectively so they can create action plans. Then, if an external auditor comes in to audit that facility, they pass due to all those checklists the software provides to ensure a facility is acting in compliance with the regulations. We’ll cover all of this and more in this podcast episode and in our upcoming webinar on the same topic on August 3rd @ 1 PM ET.

Tune in to the most recent episode of our podcast, “Compliance Conversations : How to Pass a Radiation Oncology Audit,” with guest and expert medical auditor La Tanya McNair. Don’t fail an audit. In this episode, you’ll learn how to pass a Radiation Oncology audit with flying colors. In this podcast, you’ll learn all about:

    • Isodose Plans and treatment delivery
    • Billable IMRT (Intensity Modulated Radiation Therapy) Codes and payor-specific guideline exceptions
    • Failing audits and bundling services
    • The importance of knowing the treatment plans
    • Care-specific guidelines

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Episode Transcript

CJ: Welcome everybody to another episode of Compliance Conversations. I am CJ Wolf with Healthicity, and today’s guest is La Tanya McNair. Welcome, La Tanya.

La Tanya: Thank you so much, CJ. Great to be here, and thanks for the invite.

CJ: Yes, you’ve been a guest before but take a moment to introduce yourself; tell us what you’re doing now. We know you have a lot of excellent coding experience and auditing background, and we’re going to get into that today.

Question: What are you doing now?

La Tanya: Well, currently, CJ, I am the Compliance Success Manager for Healthicity. When Healthicity brings on new clients, I will take that client under my wing and train them on how to use our Audit Manager; how to go into the Audit Manager, and use their clinical documentation to make sure the providers are documenting according to what’s being audited and to store that audit and how to build reports and professional feedback to the providers as to the audit findings.

CJ: Excellent, that’s good work. I’m sure you see a lot of variety working with clients; they’re auditing different things. Today we’re going to talk about a very specific type of auditing, radiation oncology. That can be very difficult for a lot of people, especially if they have never done it before. We know in coding and reimbursement, we do tend to specialize in different areas because it can be difficult to learn, and radiation oncology is one of those areas. In my many years of experience, people have struggled with that a little bit.

Question: Do you think that’s true?

La Tanya: Absolutely, CJ. Radiation oncology is a very specific, focused area of coding, and it takes a really key eye to be able to identify what needs to be captured during that process, so I have had the wonderful advantage of going out into the field and doing what we call new acquisitions. Which is when different providers are acquired, I would go out to train and develop those staff members on the corporation’s policies and procedures, the new organizational workflow, and things of that nature. Building successful medical coders CJ in radiation oncology, and I was what they call a ROCC, radiation oncology certified coder. I hold a ROCC certification as well.

CJ: Excellent, so you have a lot of great experience working with radiation oncology groups. We’re eager to pick your brain today. Let’s start with a broad picture.

Question: What would you say are some of the key factors that contribute to quality coding in radiation oncology?

La Tanya: Well, CJ, you know it all has to do with educating that coder on what to code. Showing them what it looks like to code weekly or the type of plans that are required that are specific to a patient’s cancer and their tumor volume. What type of documentation supports your billable codes? One of the main things about radiation oncology coding is care-specific guidelines. For example, if I’m coding something in the state of Nevada, if I were to go and code for the state of California, you’re in a whole different ball game as far as what type of code capture you’re going to generate for care specific guidelines according to those states.

CJ: Are those Medicare-specific? Are they Medicaid specific? What’s different from state to state?

La Tanya: All of the above. It could be a care-specific guideline; it could be something Medicare wants you to do as opposed to how Medicaid wants you to code that out. So it’s state-specific, its care specific. The biggest key you can ever use is following those guidelines. You want to make sure you’re looking at your care-specific guidelines for successful coding.

CJ: I probably should have started; most people know oncology is a broad specialty where you’re treating cancer. Cancer can be treated with chemotherapy and certain immunotherapies; radiation oncology is a specific kind where they use different forms of radiation to treat that cancer. So it’s not chemo. There are often machines that have to generate the radiation and shoot the radiation in a certain way, unlike other things where you’re inserting types of radiation. For our listeners, kind in mind that we are specifically talking about radiation.


You have outlined some of the key factors.

Question: What are some of the factors for failing a radiation coding audit?

La Tanya: You just nailed it in your summary of what radiation oncology is all about. One of the biggest things a coder can do when it comes to passing an audit is knowing what to look for. When we talk about the delivery of different radiation modalities, whether or not the writer is recommending the patient has a treatment 3D plan versus an IMRT (Intensity Modulated Radiation Therapy) plan versus a 2D plan. Knowing the different plans can be the determining factor in whether or not an audit could pass or fail.

You touched on something good when you talked about the modality of radiation oncology. In my personal experience, I was always fascinated by the different types of treatment a patient can undergo when it comes to how the provider decides to treat that patient’s cancer and that patient’s tumor volume, and knowing the different isotope plans can be the determining factor.

CJ: And there are physicists involved calculating certain things; it’s not always the physician doing things. I used to work at MD Anderson Cancer Center in Houston, Texas, and I was there as they were building their proton therapy center, which at the time, this was many years ago, was the newer type of treatment modality. I remember touring the facility, and it was like a mini nuclear plant. It seemed like with all the safety equipment and all the things going on.

Question: You mentioned IMRT, that stands for Intensity Modulated, right?

La Tanya: Exactly, intensity modulated radiation therapy, and you make a very good point, CJ, when you talk about touring the facility because I had the advantage of sitting down with certain physicists and dosimetrists and having them explain the various treatment plans because I wanted to be able to take that information back to the medical coders and say when you’re looking at this plan, this is a 2D plan, this is a 3D plan, this is an IMRT plan, to give them that visual effect because as you know sometimes a physicist and a dosimetrists, they’ll get together and draw up multiple plans that cater to target treating that patient’s tumor volume and present that plan to the provider and the provider makes the determination on which treatment plan best treat’s that patients cancer and go in and treat that patient’s tumor volume. So a wonderful experience and very advantageous for a coder to know the different treatment plans.

CJ: I agree with you if you’re going to be involved in this area. It’s such a unique area of coding and medicine. You think of other areas of medicine, like surgery, where you read the operative report; they’re cutting things out and this and that. With radiation oncology, it’s almost like its own little world where there are all these different specialists like the dosimetrist, the physicist, and they are using special equipment that’s really unique, so a lot of the terminology, a lot of the medicine, the medical approaches so sitting down with these professionals is a good way to have them walk you through these specific types of plans. The other I remember is the difference between the technical component and the professional component.

Question: Some codes are only technical, correct me if I’m wrong; some have both, and some might only be a professional component. Is that accurate?

La Tanya: That is totally accurate, and sometimes when we talk about capturing the technical component versus the professional component, it can get really tricky, and it depends on that provider when they’re doing certain images, if they are signing off on those images in a timely manner, can be the determining factor on whether you’re going to capture the professional component or the technical component. So you really have to pay attention because some of those documents are very time sensitive. You’re absolutely correct.


CJ: Good, so tell us a little bit about documents.

Question: What type of documentation should the medical coder look for when they are starting these types of reviews and audits?

La Tanya: The first thing I would recommend to a coder when you talk about how radiation oncology. I always say radiation oncology fits like a puzzle. You know how when you’re looking at a puzzle, and you want to build a puzzle, you can look at a puzzle and identify, say, the end pieces and then try to pick apart the various colors that are in a puzzle. The same principle applies to radiation oncology. You’re identifying key documents that are needed to fit that overall puzzle to code for radiation oncology, and when you talk about auditing and documentation that auditors want to see or if you get audited from an external auditor, what do they want to see, you want to make sure that you have nots from the referring physician, you want to make sure that the documentation contains ENM council visit. You want to make sure you have a treatment plan and an isotope plan, and there are very specific documents that you would find in that chart. Whether or not they are weekly documents or daily documents, in order to fit the big piece of that puzzle, you want to look for specific daily treatments, weekly treatments, that sort of thing.

CJ: Yeah, I think you pointed this out. A patient has cancer, they’re typically not diagnosed by the radiation oncologists, and they are diagnosed by somebody else, so there’s this initial consult or referral. Maybe it’s a surgeon, maybe an oncologist saying we feel that these treatments might be helpful, but we feel radiation might be helpful, we need to get a consult. That’s the initial introduction to radiation oncology, and then as you mentioned, that consult will result in some sort of treatment plan. They decide what kind of radiation to give, how many doses, and then they simulate it before they actually shoot you with real radiation. They do a simulation because they want to isolate the area of cancer. The goal here in oncology is to kill and target the cancer cells without damaging healthy cells. There are very precise measurements, and computer models are used, so you are developing this plan, and then you mentioned those weekly visits. You mentioned weekly physics reports, port films, blocks; they have to make these blocks to protect actual tissue. Physical blocks are shaped in a certain way so that radiation goes through the open spaces and not the blocked spaces to protect healthy tissue. All sorts of things, special dosimetry, and then there can be changes in the client, right?

La Tanya: Exactly. Yes, you make a wonderful point, CJ, because I’ve always been fascinated by specifically when a provider decides to treat a patient with a combination of IMRT plan and an IGRT (Image Guided Radiation Therapy) plan. IGRT is that image-guided radiation therapy, so when you talk about administering that radiation to a patient tumor volume, and then we talk about how the IGRT comes in and as different parts of your body move, how the image-guided part of that is still able to administer that radiation to that tumor volume and maybe your body is moving at the same time, and the IGRT is focused in with the moving part so that it can still protect the radiation from going to other structures that you don’t want to receive that radiation. It is the most fascinating thing I’ve ever seen is to do IMRT in combination with the IGRT to protect those critical structures, like you said, CJ. It’s amazing.

CJ: Yeah, and patients usually get the actual radiation on a weekly basis, right?

La Tanya: Yes.

CJ: And it may vary. Correct me here. 4 to 8 weeks is typical.

Question: What have you seen as the total treatment time?

La Tanya: Absolutely, it would be very typical to see a 4 to an 8-week treatment plan. And you just touched on something really important. When we talk about weekly visits but you have to make sure you are paying attention to the treatment log because certain patients, depending on what’s being treated, I have actually seen where they have on a daily basis that a patient would come in for an AM treatment and then turn around and come back in for a PM treatment. So when we talk about specific codes that are required, we also want to touch on based on specific modifiers that are required when you are treating, say, an AM patient that is coming in for that PM visit also because we have to use specific modifiers to identify those AM and PM treatments.

CJ: That’s a good point because that’s all the same date of service and the claim; from a submission perspective, it could come up like why you double are billing, but you have a morning radiation and an afternoon or evening. Good point.

La Tanya: Exactly.

CJ: Let’s talk about how some of the miss-steps get enforced with OIG (Office of Inspector General). Facilities and groups that were hit hard with OIG and DOJ (Department of Justice) penalties, I have seen some things in the headlines.

Question: What are your thoughts?

La Tanya: Oh my gosh. Remember how we were talking about the key factor is knowing those specific isodose plans and the treatment modality and how they are going to go about treating that patient. When you talk about OIG penalties, it’s because they are not only coding and billing those improperly, it’s because of the unbundling also because with that initial treatment plan comes with simulation and other code-able events that need to be bundled into that treatment plan, so you want to make sure you are not unbundling those.

CJ: Yeah, I have tried to explain to physicians in my years of working with them. They want to report every single step of code because they did all of those things and they want to get all their credit, but to your point, if it’s all bundled. The example I use (it came from one of my mentors) for everyone in my career is it’s like a value meal. If you go through a fast food drive-through and order the burger, fries, and drink separately, that’s unbundling, and you are going to end up paying more. If you buy it all as a value meal, it costs a little less and is all bundled in together. Certain things are included in that overall price, and certain things are not. I think you mentioned the simulation is a part of that IMRT plan and where some practices get in trouble is where they unbundle that and use modifiers to get them paid.

Question: You’ve seen penalties in that regard, right?

La Tanya: Exactly, especially when looking at OIG reports on how hard hit radiation oncology was and specifically when I look at reports from, say, 2013 to 2015, Medicare paid millions in overpayment for unbundling of the IMRT and those simulations.

CJ: Yeah. The other thing that I have seen and La Tanya, I wonder if you can talk a bit about this, is proper supervision. So a lot of physical locations for radiation oncology might be a satellite departments of the hospital. For the hospital to bill those, there has to be proper supervision, and that may mean a physician has to be on-site, and those rules can change a little bit.

Question: But supervision is also a part of it, right?

La Tanya: Right, it is CJ. I have seen different radiation oncology provider groups get in trouble because sometimes they will hire what they call a sit-in physician to come in when the primary physician is going to be out. They use the term for some of those sit-ins as like babysitter doctors, and I know the providers don’t like that term, but sometimes they still use that term, but they can get into a lot of trouble when like I was telling you the documentation, when it’s not signed off in a timely manner, and then you’re still billing the professional component as if you were still there and signing off on that. Specifically, one group was hit with a $91,000 violation for not having the proper supervision and timely review of those documents. So they have to really be careful.

CJ: Yeah. There was another one, you had shared some information with me, there was another radiation group that paid 3.5 million last year, and it had to do with lots of things like incorrect codes, dates of service, and incomplete documentation.

Question: Any thoughts on the details of that particular settlement?

La Tanya: Right, and it happens all the time CJ where you would think if you are not paying attention to the treatment plan and you’re coding something that is for a 3D plan, and it should be daily treatments and IMRT plan because the codes are going to be different. So specifically with radiation oncology, where you are seeing that patient every single day, and so you are building lots of codes, the more codes you are coding, and if you are coding those incorrectly, that just fails, fail, fail, on after another. In radiation oncology, that delivery is not cheap, very expensive treatments, and that’s why the industry gets hit really hard because it is very costly.

CJ: Exactly. One other thing that I recall is some practices getting in trouble with incorrect dates of service. As we know, a lot of the edits, the correct coding initiative edits relate to codes reported on the same date of service, and so they may have reported everything on the same date of service but in order to get a service paid, they report it on a different date of service so it unbundles and I have seen some issues where incorrect dates of service have been reported, and that’s led to compliance enforcement.

Question: Is that something you have seen as well?

La Tanya: Exactly, CJ. You can’t falsify the records. You have to report it as it’s happening. I always tell people radiation oncology is very unique to coders because we do what we call abstract coding. You don’t have someone that has, like, say a superbill telling you to code this on this day and code that on a different day. You’re coding according to what your documentation supports, and if you are falsifying that in any type of way, you are going to get into a lot of trouble. So you have to code it on the day that the service occurred.

CJ: Exactly. Sometimes there are electronic billing systems specific to radiation oncology that are used, and people set them up to say when we drop this client, we want it to explode to these multiple codes and report them on these dates of service and to your point if it’s not legitimate that those dates are the actual date you did it then that’s a problem. I am glad you pointed that out.

La Tanya: In our profession, one of the best things a coder can do so they are not unbundling is to run a report on the codes that they have already submitted. Run that report because, truly, radiation oncology is like a puzzle. If you initially run that report to see what you have built and compare that to what your documentation supports, you will be able to see how that puzzle fits together.

CJ: Yes. I am wondering about your current role in helping clients with the Audit Manager software.

Question: Could you talk about some of the advantages of software like that for people who are dealing in these types of audits? How does that help them?

La Tanya: Absolutely, CJ. Healthicity has the Audit Manager software, and within that software, radiation oncologists and many multi-specialty providers can build what we call a documentation checklist and procedure checklist. So when we talk about things that have the potential to be unbundled, you can create your documentation checklist to specifically check to make sure you are not unbundling those various procedures and also create customizable documentation checklists to make sure that revenue-wise, you are co-capturing everything that is billable from a revenue cycle standpoint. You are maximizing capturing that revenue for your organization, and the Audit Manager software is amazing at customizing those checklists and would really benefit any multi-specialty providers, including radiation oncology.

CJ: The clients are lucky to have you then because it sounds like you help customize it for them when they need that help.

La Tanya: Exactly, CJ, and thank you for pointing that out.

CJ: Good. Well, we are getting close to the end of our time. I wanted to make sure I leave you time for any last-minute comments or a summary.

Question: What kinds of major things do you think are important takeaways from our discussion today?

La Tanya: I think one of the main takeaways I want to focus on is for the medical coder to know your plan, to run those reports, to use the Audit Manager software to build those documentation checklists, those procedure checklists, and as an auditor, whenever the auditor does a final audit finding and make that final recommendation that the managers, the directors, are paying attention to those audit findings because the Audit Manager software has these really robust reports that auditors use to communicate to the managers and directors so they can create action plans so that if an external auditor comes into audit that facility they pass those audits based upon the software and building those checklists to ensure their facility is acting in compliance with the regulations. And you touched on that many times before. What type of organization are you working for or working with? Is it a compliant organization because truly that is where you want to be? You want to make sure your organization is compliant in doing things properly.

CJ: Absolutely, and you want to walk the line too because you don’t want to leave legitimate revenue on the table. I’ve never been one to say go severely under code to where you are leaving legitimate revenue. You’ve done the service. This is expensive, you want to capture every legitimate charge, and you just don’t want to cross that line. One thing that I found really helpful, and you’ve mentioned, is already know your payer guidelines. A lot of these patients, not all, will be older like Medicare patients, and I think it’s essential that you look at Medicare guidelines, especially the national correct coding initiative, when it comes to these codes. I recall a conversation I had with some radiation oncology groups that I was helping, and they said well, the CCI edits say we can use modifier 59, so we’re going to use it. Well, you are only allowed to use that if it’s a legitimate use. It doesn’t mean use it all the time. It means use it when the circumstances are appropriate. I think some groups have gotten into trouble because they have used these modifiers inappropriately to bypass payer edits and knowing Medicare guidelines through your LCD, your local coverage determination or if there is a national coverage determination, knowing those specific requirements because some of those policies get really detailed.

La Tanya: Exactly, and you make a very good point, CJ, because sometimes, as an auditor, if we see that you are overusing anything and we run a report, that gives us the ability to take a deep dive to see if you are really using those codes and those modifiers properly. So overutilization is a red flag.

CJ: Absolutely, and you are not the only one doing it internally. OIG and other enforcement agencies are doing it externally. They have national data. They can find the people who are outliers. That does not mean they are automatically doing it wrong, but if you are overutilizing, they are going to do a deeper dive, and they will find out.

Well, this has been a great conversation, La Tanya. Any last-minute thoughts before we close up?

La Tanya: CJ, it is always a pleasure.

CJ: Absolutely. Thank you for your expertise, and thank everybody for listening to another episode of Compliance Conversations. We look forward to having future guests and having you as listeners listen in to our future podcasts. Thanks for listening.

La Tanya: Thank you CJ.

Questions or Comments?