Don't Undercode: Bill Level Five for Payment of Cognitive Services

July 1, 2007

A large part of delivering high-value cancer care is devoted to cognitive services, which are very difficult to quantify within the current coding system. Achieving appropriate payment for cognitive services delivered is an ongoing dilemma within the oncology community.

A large part of delivering high-value cancer care is devoted to cognitive services, which are very difficult to quantify within the current coding system. Achieving appropriate payment for cognitive services delivered is an ongoing dilemma within the oncology community.

Within the current political climate, a dramatic change of culture is needed for oncologists to get properly paid for cognitive services. A major flaw in today's healthcare system is the "philosophy" created over the past several years in which physicians are paid solely on the volume of patients they see and the number of services they render—not on the quality of care they provide. We should embrace the concept of value-based purchasing by insurers for their beneficiaries.

Paying for cognitive services rather than paying for ancillary services or volume will result in the best care and best dollar value for the healthcare system.

Oncologists should stop worrying about the threat of audits and have confidence that their documentation meets the criteria to bill level fives. I have won many Medicare audits based on our physicians' proper billing documentation. As a matter of fact, the real threat to oncology is physicians who are undercoding. When you analyze their documentation, they're actually doing bona fide level-five work, delivering complex care but billing for routine care.

The message is simple. A 10-system review in an 8-system examination with a stable patient is always a level five, no matter how many times it's billed. It's important to note that 80% to 90% of patients who walk into a cancer center walk out the door stable, even though they have progressive disease. More and more patients are going back to work, going on trips, and watching their kids celebrating birthdays. What does that say? It says that oncologists are doing a great job, but they're not billing accordingly.

Oncologists must have confidence that the services they're delivering are highly complex. Every day oncologists deal with death and dying and highly intricate psychosocial issues, but in the AMA's scheme of things, oncologists are put on the same playing field with internal medicine and family doctors.

The reality is, if internal medicine doctors are billing level-three visits, oncologists should be billing level fours and fives.

Oncologists have historically under-billed for their services, and it has come back to haunt them. When the Centers for Medicare & Medicaid Services (CMS) determined how they were going to assign a professional work value for cognitive services, they saw that the majority of the codes being billed were level-one (99211) office visits. So they chose the 99211 code to extrapolate the professional work value, and assigned it to the chemotherapy administration codes. Hence, complex oncology services were undervalued. The oncology community should be lobbying Congress through the AMA, strenuously explaining that the wrong professional work value was assigned to chemotherapy administration—CMS should have used at least a level-four work value.

Further, it is vital that we educate physicians on how to capture the complexity of their services through comprehensive documentation and billing processes, and educate the insurers on the true value of the care rendered.

People keep asking how are we going to define pay-for-performance. The answer is very simple: If practices properly document their cancer care services, then CMS will see pay-for-performance in the positive outcomes that result from doctors focusing on quality rather than on volume.

The drug margin is shrinking; in order to remain healthy, practices must adapt to the new environment and properly bill for all their services. In placing value over volume, the health of oncology practices and their patients will benefit.