Capture Advance Care Planning Revenue with Expert Oncology Billing Services

 

Advance care planning is a routine service provided by an oncology practice. Simply put after a patient's disease progresses, oncologists are forced to converse about the steps the patient, and his/her family would like to consider if treatment stops responding; like palliative care.  

Now these discussions could last for minutes, if not hours. But most of the time claims are submitted with a standard E/M code and all the minutes oncologists spend on such conversations go unreimbursed. Expert oncology billing services are built to reduce such revenue losses.  

What CPT 99497 and 99498 Actually Cover  

For such conversations on advance care planning or ACP, oncologists can seek reimbursement and the applicable codes will be CPT 99497 and 99498. 

• The prior describes the first 30 minutes of face-to-face conversation practitioners have on ACP with a patient, their family or even a surrogate.   
• The conversation can include aspects like living will, health care proxy and so on.  
• The latter, acts as an add-on code for every additional 30 minutes of discussion.   

The most asked question here is when CPT 99497 and 99498 are reportable. The first becomes reportable at 16 minutes of discussion, and gradually the latter applies once the conversation reaches 46 minutes or longer.  

Why These Services Are Often Not Reported  

Oncology care workflows are built around major treatment related discussions and decision making. Naturally any discussions on ACP tend to get blended into regular discussions. Simply put, most of the time the minutes go unrecorded, and the note vaguely mentions discussions on goals of care. And coders are then left with nothing to support such time-based codes.   

Furthermore, some practices believe hospice and palliative care are the same thing, and then lose on potential revenue. This is frustrating given ACP can be reported even when a patient is receiving active cancer care.  

Things become more complicated with confusion between terminologies. For example, palliative care deals with improving quality of life during serious illness. But ACP is a specific, time-based service. Now practices that have an embedded palliative care team, often offer both the services under the same visit and fail to bill them separately. Lastly, given the time-based nature of these codes some practices even worry about increased scrutiny from payers. An expert oncology billing services team has proper understanding of all these potential leaks and develops personalized workflows to manage them.   

Documentation That Supports the Claim 

Now the question might be how to get reimbursed for ACP conversations and at the center of that answer sits proper clinical documentation. For coders to assign the relevant codes and for oncologists to get reimbursed for it, documentation must show: 

• Discussion was voluntary, information on the participants and the contents of the discussion and the total minutes spent.  
• It should also explain why the conversation was necessary like disease progression, a new line of therapy, or a decline in functional status. 
• The time must also be separate from any other management of the patient's problems.  

An expert oncology billing services team understands these requirements, and helps manage the same. 

Claim-Level Details That Trip Up Payment  

Practices can bill ACP on the same date as the E/M visit. However, there are some exceptions in the case of critical care services. In case the ACP is getting billed with the E/M service, then some payers may require the modifier 25 to be used along with the relevant E/M code.  

Additionally, if the ACP is taking place during a Medicare Annual Wellness Visit, modifier 33 may need to be used along with the CPT 99497 to remove patient cost sharing. Otherwise, deductible and coinsurance apply. 

It is noteworthy to mention here that requirements vary significantly from one payer to another. Most commercial insurance plans have distinct pre-requisites for how often a service can be provided, where it can take place, and so on. 

What the CY 2027 Proposed Rule Could Change  

CMS’s proposed 2027 rule would create two new codes, GACP1 and GACP2, for advance care planning provided by clinical staff under a practitioner’s direct supervision. 

• CPT codes 99497 and 99498 would cover only the time spent by the practitioner. 
• Both staff and practitioner codes could be billed together if each meets the required time limit. 
• CMS also proposes allowing the new codes for Medicare telehealth services.

However, the rule is not final. Practices should start recording staff time and practitioner time separately while waiting for the final decision. 

How Expert Oncology Billing Services Close the Gap 

This kind of complexity is what an expert oncology billing services provider was built to manage. They start by reviewing the charge captured and compare the visit timelines and clinical documentation against what was billed. This enables them to identify where ACP is going unreported. Accordingly, they work with oncologists to capture accurate start and stop times of ACP discussions, and participating parties and the clinical rationale behind it.  

After that, their in-house coders help review each claim against payer-specific guidelines on modifiers, frequency limits, place of service and so on. Such pre-submission review helps keep denials at bay. Even if any denial occurs, an expert oncology billing services team will be able to identify the problem like time documentation, a hospice conflict, promptly through a deep root-cause analysis. 

These expert teams also track policy changes and help keep practices compliant with recent updates, and thus create an oncology revenue cycle that is audit proof. 

Advance care planning is a crucial part of cancer care and expert oncology billing services teams make sure practitioners get paid for their services fairly. 

Hire ophthalmology billing services to improve fundus photography RCM

 

Ophthalmologists often have to distinguish between medical eye care and routine vision benefits, while handling specific reimbursement policies. Eye care is not only limited to regular eye checkups but also deals with other detailed medical procedures and services. One such ophthalmology service is fundus photography, which is a major imaging procedure. This itself becomes challenging for many providers, which makes fundus photography a critical aspect of ophthalmology services.

Moreover, practitioners often struggle to get bill insurance claims for fundus photography services. This is one of the reasons why eye care specialists hire outsourced ophthalmology billing services for the required support. These professional billing companies have the expertise to handle the complexities of fundus photography reimbursement. That being said, it is important for every provider to understand how fundus photography billing works before they hire a third-party company. 

How does a fundus photography billing process function?

Patients may often face issues or discomfort in their retina or optic disc. This is when a fundus photography is required to record any abnormalities in the retina or monitor an eye disease. There is one thing which makes fundus photography unique than other ophthalmology procedures. This process does more than just capturing retinal images. It helps clinicians identify damage patterns and determine whether additional eye testing or monitoring is required. 
 
Difficulties arise when clinicians have to submit insurance claims for reimbursement of fundus photography. Providers often find it challenging to get proper reimbursement for this ophthalmology service. One of the key elements that make fundus photography billing unique is the use of CPT code 92250. It is used to document retinal findings and monitor changes that are associated with eye disease.  
 
Outsourced ophthalmology billing services not only prioritize documentation but also ensure authorization, coding and other reimbursement tasks are in place. Now the question may arise why providers need to hire outsourced companies for ophthalmology billing. This is mainly because of certain hindrances that restrict ophthalmologists to achieve the required reimbursement rates. 

Navigating the major challenges of fundus photography billing

Most eye care clinics have an in-house billing team that performs all the required reimbursement tasks. However, most in-house staff face the following changes, which creates the need for professional ophthalmology billing services. 

1. 1. Incorrect coding – Having the proper knowledge of medical codes is something that requires years of experience and expertise. It is also important to have the knowledge of when and where to apply the correct modifier. This helps providers receive proper reimbursement for services.  
    
   In many cases, the CPT code 92250 is applied incorrectly in ophthalmology reimbursement. It is used when the service actually performed is a different type of retinal imaging, such as OCT with quantitative analysis. The correct code that must be applied in this case is CPT 92314.  
    
   Let us assume that a patient undergoes retinal imaging during an ophthalmology visit. Provider’s documented record shows that the purpose of testing was to measure and analyze retinal thickness using OCT. However, the billing team submits CPT 92250 for reimbursement of fundus photography.  
   
   

2. 2. Payer-specific policies – It is quite common for clinics to work with multiple insurance companies having different billing policies. The coverage policies of Medicare may vary by jurisdiction, and commercial insurers may have their own medical policies. The issue occurs when a payer may cover fundus photography for a documented retinal condition but not for routine screening. 
   
   

3. 3. Documentation requirements - When providers perform fundus photography, it does not guarantee reimbursement. The medical record must support why the procedure was performed, what service was performed, and whether the service meets the payer's requirements. 
   
   

4. 4. Claim denials - Submitting claims with incorrect documentation or coding can lead to claim denials. The real challenge begins when ophthalmologists are not aware of what to do with the denied claims. As a result, they lose revenue and are unable to recover outstanding balances. The task is made easier by professional ophthalmology billing services who are experts in denial management. These companies correct the denied claims and resubmit them for proper reimbursement. 

Ways in which outsourced billing companies are beneficial for fundus photography RCM 

When problems occur, seeking solutions for them becomes the task of medical providers. Hiring an ophthalmology billing company can significantly reduce errors and improve fundus photography reimbursement. The question is how this becomes possible for outsourced companies. Let us understand the ways in which professional billing companies improve fundus photography reimbursement.  

1. 1. Accurate coding - Outsourced ophthalmology billing services have the knowledge of codes that are used for fundus photography. They ensure that claims are submitted with accurate codes which help in reducing denials and improving reimbursement rates. 
   

2. 2. Medical necessity and documentation checks - The billing team checks whether the patient's documented condition or clinical circumstances support the need for fundus photography. For example, imaging may be used to evaluate diabetic retinopathy or document changes associated with glaucoma, subject to the applicable payer's coverage policy. Billers also confirm that the medical record matches the service that has been billed. This may include clinical indication, relevant examination results, and physician interpretation reports.  
   

3. 3. Denial management - Professional ophthalmology billing services use denial management methods to recover outstanding payments for fundus photography services. Fundus photography is commonly used to document and monitor retinal and optic nerve conditions, including diabetic retinopathy and glaucoma. The billing team reviews the insurer’s EOB to determine the reason behind fundus photography claim denial. They also make the necessary coding and documentation changes before claim resubmission. 

Factors to consider before outsourcing ophthalmology billing

The most important thing to remember before hiring external companies is to verify if they are experienced in handling fundus photography reimbursement. Additionally, providers must also check if the outsourced ophthalmology billing services have certified coders and trained professionals. Improving revenue cycle management can become much easier by partnering with an efficient billing company. Providers can not only achieve financial stability but also witness improved patient care in the long run.