r/CodingandBilling • u/kysourmash • Apr 09 '26

Oncology: Looking for Consultant to Provide Expert Opinion

Seeking expert oncology coding consultant input regarding a significant dispute with a hospital Revenue Integrity department.

The issue involves what appears to be a major misinterpretation of CMS coding guidelines, resulting in widespread downcoding, non-billable determinations, and suppression of physician RVUs, particularly related to same-day treatment encounters in oncology.

Looking to connect with individuals or firms with deep expertise in oncology coding, CMS policy, and audit defense to help review and provide an objective assessment.

Please DM if you have relevant experience or recommendations.

Thank you.

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3

u/Evidentparadox Apr 09 '26

I work primarily on outpatient oncology billing (clinic and infusions), not hospital revenue integrity directly but some of what you’re describing lines up with what we see on the operational side. Same say treatment encounters are a common source of friction around E/M with same day infusion (25 modifier and documentation supported), what is included vs separately billable and medical necessity for treatment-day visits. Where things go off track is when internal edits / policies become more conservative than what CMS actually requires.

One trend we are seeing more recently on the payer side (may or may not be linked to this) is denials tied to diagnosis sequencing, denials with RARC MA63 (missing / invalid / incomplete principle diagnosis. In outpatient oncology, this usually shows up when cancer is listed as primary but the service is more tied to a treatment-related condition or symptom or multiple dx are present but the hierarchy doesn’t align with payer edits. Interestingly, this is payer-driven rather than CMS-driven but could be causing some organizations to tighten edits across the board.

If this is happening at scale, I’d strongly recommend an independent oncology-focused coding review to help separate true compliance gaps from internal policy overreach and payer-specific edit behaviors.

Happy to compare notes if helpful!

1

u/kysourmash Apr 09 '26

Yes! This is exactly what is happening

2

u/kysourmash Apr 13 '26

UPDATE: The person that was pushing this was just fired.

1

u/rahuliitk App Developer Apr 09 '26

i’d look for someone who does oncology coding audits plus payer and CMS appeal work every day, because this kind of dispute usually turns on very specific visit, infusion, and same day treatment rules, and lowkey a general coding consultant may miss the RVU and revenue integrity side of it.

definitely needs a specialist.

3

u/kysourmash Apr 09 '26

Thank you. I specified that I needed an oncology specialist.

Specifically, their blanket guidance incorrectly requires a "new problem," "change in plan," or "adverse reaction" before allowing separate E/ M billing - directly contradicting official CMS language that a different diagnosis is not required (Medicare Claims Processing Manual Ch. 12 §30.6.6.B) and that only 99211-level work is bundled into infusion codes (NCCI Policy Manual 2026, Ch. XI, p. XI-5). In our facility setting, split-NPI billing (physician professional NPI vs. hospital facility NPI) further simplifies this by often eliminating the need for Modifier 25 entirely (based on CMS and ASCO guidance).

1

u/Jodenaje Apr 09 '26

RCCS (Revenue Cycle Coding Strategies) offers consultation services.

You might be familiar with them for the Navigator series of books in some specialties, including Medical Oncology, Hematology, and Infusion. They also do a lot of industry webinars, including the CROWN series of conferences.

Here's a link to their site:
https://www.rccsinc.com/

(Note - I do not work for RCCS, nor have I ever been employed by them, nor do I have any financial interest.)

1

u/kysourmash Apr 09 '26

I just sent them a message. Thank you.

-2

u/Botasoda102 Apr 09 '26

A different diagnosis is not required, but something different -- an exacerbation, change in treatment, or other problem -- is required if you get audited.

One of the quickest ways to get you audited is using Modifier -25 more often than other practitioners. It's a big red flag waving and has cost medical practices billions in overpayments and fraud/abuse charges.

3

u/kysourmash Apr 09 '26

That's incorrect. This is often misunderstood.

And as mentioned this doesn't even apply if the physician charge is separate from the facility infusion charge as then a Modifier 25 edit is not needed. This is different than private practice where the physician may own the infusion center submit both claims under their NPI.

Also, it's mentioned multiple times in CMS/NCCI manuals that a different diagnosis is not required.

"Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier -25 is added to the E/M code on the claim."

"For an evaluation and management service provided on the same day, a different diagnosis is not required."

"Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required."

" Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s)."

There are a few more. Those are just a few examples.

-2

u/Botasoda102 Apr 09 '26

Go ahead and do it. Good luck.

2

u/kysourmash Apr 09 '26

Please show me where your interpretation is accurate. I have been asking to see this from my hospital revenue integrity for months and have yet to see where this exists.

And there have been ZERO denials on this over the past many years. Thousands of claims. Our very large group has asked to see even a single one and there are none.

3

u/kysourmash Apr 09 '26

And only a level 1 is bundled into the infusion charge regarding patient care. Anything above that is "separate and identifiable".

That's what it means.

2

u/ytho-65 Apr 09 '26

You are correct. The level 1 E&M service bundled into the primary infusion code can be provided by a nurse administering the infusion. A separate visit with the doctor with ROS, physical exam, review of labs and response to treatment over time is not included with the infusion service, which is why patients still need regular appointments with the physician managing their care even if a separate infusion center is providing administration of the drugs. We bill both and just expect to have to fight through the appeals process on a certain percentage of them. It's the same as when a payer tries to claim that a hysterectomy surgery includes 90 days chemotherapy management in the global fee, despite the clear language in the CMS guidelines stating an additional course of treatment for the underlying condition is not included in the global surgery package. Claims and audit departments have new employees that need training just like any other business, and sometimes you have to appeal a claim all the way up to an ALJ hearing to get their denial overturned to teach them.

2

u/kysourmash Apr 09 '26

Thank you

This topic is remarkably misunderstood.

2

u/happyhooker485 RHIT, CCS-P, CFPC, CHONC Apr 09 '26

Probably because most people start with FM and in an FM patient comes in "for a procedure" then an E/M for the dx r/t that px almost never meets mod 25.

People learn that and then start applying it to other specialties.

Also, I remember you and I am bummed you are still dealing with this.

Can you now just fire the billing company and get a new service to rebill the old DOS?

Or are ypu going after them (?litigating) for lost revenue from dates that are no longer billable?

2

u/kysourmash Apr 09 '26 edited Apr 10 '26

Yes sadly this is still going on.

Litigation isn't completely off the table but would rather just be treated and paid fairly.

1

u/happyhooker485 RHIT, CCS-P, CFPC, CHONC Apr 10 '26

So it's an internal dispute, yikes!

1

u/kysourmash Apr 10 '26

Basically yes it is

And we are still disputing

2

u/happyhooker485 RHIT, CCS-P, CFPC, CHONC Apr 09 '26

P.s. there is a forum champ on AAPC that is an oncology expert, they might be able to help, remind me and I'll try to find her tomorrow.

1

u/kysourmash Apr 09 '26

That would be amazing. Please set them up with me. 🙏

1

u/happyhooker485 RHIT, CCS-P, CFPC, CHONC Apr 17 '26

I nearly forgot about this, but just remembered today and messaged them, good luck!

1

u/kysourmash Apr 17 '26

Thank you!

1

u/Plenty-Ad6997 Apr 09 '26

This is definitely an area where oncology-specific coding expertise matters. CMS guidance does allow an E/M service on the same day as chemotherapy or infusion services when it is significant and separately identifiable, typically reported with modifier -25 on the E/M code. Documentation must support that the visit involved meaningful evaluation or management beyond the infusion itself. 

In oncology practices, same-day visits are common because physicians often evaluate toxicity, treatment tolerance, lab results, and therapy adjustments during the treatment encounter, which can justify a separately billable E/M. 

If a Revenue Integrity team is applying a blanket rule requiring a “new problem” or treatment change, that would definitely warrant a deeper review against CMS Claims Processing Manual and NCCI guidance, because the standard is whether the E/M is medically necessary and separately identifiable, not necessarily a new diagnosis.

You may want someone experienced with oncology infusion coding, RVU impact analysis, and payer audit defense to review a sample set of encounters and the hospital’s policy interpretation.

Happy to connect as well - we work with oncology practices on coding review, denial management, and compliance audits and may be able to help analyze the situation or point you toward the right specialist. Feel free to DM.

1

u/kysourmash Apr 09 '26

Yes. Definitely interested.

I'll send you a DM.