Risë Marie Cleland

 Can you please explain the coding rules for “concurrent” infusions? 

 When two drugs are hung in two separate bags and are administered simultaneously and one of the drugs is a therapeutic/diagnostic drug, you can bill one unit of a concurrent infusion (90768). You would report an initial or subsequent administration for the first drug and a concurrent administration for the second drug. Bill 90768 in conjunction with 90765, 90766, 96413, 96415, or 96416. 

The concurrent infusion code can be billed only once per patient encounter, regardless of the length of the infusion. There is no “con-current” chemotherapy infusion code. The drugs must be hung in separate bags. The AMA publication “CPT Changes 2006: An Insider’s View” states, “An infusion consisting of three substances in a single bag is not intended to be reported as three separate infusion services, because the parenteral administration codes are intended to report the separate work of administration and IV access and not the inclusion of multiple agents in a bag prepared prior to infusion.” If an infusion lasts 15 minutes or less, it meets the definition of a push and the appropriate push code (initial or subsequent) should be reported. In this situation, the infusion would be reported as one push; however, each substance or drug would be separately reported. 

 If a patient comes in for an injection and the nurse also flushes his port that day, can we bill the port flush (96523)? 

 No. According to the American Medical Association CPT, a port flush, 96523, is not separately billable when a drug infusion or injection is provided on the same day. For Medicare patients, a port flush is only billable when no other Medicare Physician Fee Schedule service is provided. 

 We have some patients who have Medicare as their primary insurance and another third-party payer as a secondary insurance. Quite often the secondary payer will pay more than the 20 percent coinsurance. In these cases the total payment collected on the service is greater than the Medicare allowable. Can we keep the amount that is over Medicare’s allowable? 

 CMS states that physicians and suppliers who accept assignment by choice or by law are not allowed to collect from a beneficiary or private insurance an amount that, when added to the Medicare benefit, exceeds the Medicare allowed amount. Collecting more than the Medicare allowed amount is a violation of the assignment agreement. Assignment is a written agreement between beneficiaries, their physician, and Medicare. The beneficiary assigns the claim to the physician, allowing the physician to receive payment directly from Medicare for covered Part B services, equipment, and supplies. In return, the physician agrees to accept the Medicare- allowed payment amount by the carrier as his full charge for the items or services. 

The “Medicare Claims Processing Manual” states: “If the enrollee has private insurance in addition to Medicare, the physician/supplier who has accepted assignment of SMI benefits is in violation of his/her assignment agreement if he/she bills or collects from the enrollee and/or the private insurer an amount which, when added to the Medicare benefit received, exceeds the Medicare allowed amount. If it comes to a carrier’s attention that a physician/ supplier has received an excessive amount, inform him/her to refund such amount to the appropriate party. Where it is not clear as to who is entitled to receive the refund under the terms of the private insurance, any excess amount paid by the enrollee may be returned to the enrollee.” 

 How can I be sure that all of the regulations are being met when services are billed incident to my services? 

 Qualifying incident-to services must be provided by a caregiver whom you directly supervise and who represents a direct financial expense to you (e.g., a W-2 or leased employee, or an independent contractor). 

You must be present in the immediate office suite to render assistance if needed. However, you do not have to be physically present in the treatment room while the service is being provided. If you are a solo practitioner, you must directly supervise the care. If you are in a group, any physician group member may be present in the office to supervise. 

If the supervising provider is not the ordering provider, incident-to services should be billed under the supervising physician. 

Incident-to services must be part of your patient’s normal course of treatment, during which you personally performed the initial service and you remain actively involved in the course of treatment. More specifically, incident-to services must be: 

An integral part of the patient’s treatment course; 

Commonly rendered without charge (included in your physician’s bills);

Of a type commonly furnished in a physician’s office or clinic (not in an institutional setting); and

 Where can I find the current year’s conversion factor for determining the Medicare payment amount? What is the conversion factor for 2008? 

 Each year, CMS posts the current year’s conversion factor on its Web site, www.cms.gov. As a result of the Medicare, Medicaid, and SCHIP Extension Act of 2007, effective for claims with dates of service Jan. 1, 2008 through June 30, 2008, the conversion factor will be $38.0870. Unless Congress takes further action, on July 1, 2008 the conversion factor will revert to $34.0682, as stated in the Medicare 2008 Final Rule. 

 What portion of a visit can ancillary staff perform and document? Can they perform and document the history of present illness (HPI) or chief complaint (CC) if I read their documentation and notate that I have done so and agree with it? 

 According to the 1995 and 1997 E&M documentation guidelines, the only portions of the history that may be recorded by the ancillary staff of a physician are the Review of Systems and Past/Family/Social History, and those portions must be reviewed by the physician. The physician must also write a statement supplementing or confirming the information recorded by the ancillary staff. 

CMS recently clarified that only the physician or nonphysician practitioner who is conducting the E&M visit can perform the HPI and CC, stating that this is physician-level work and shall not be relegated to ancillary staff. 

The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded, or scribed, and write a notation that she reviewed it for accuracy and did perform it, adding to it if necessary and signing her name. 

 Is it true that we can now bill Medicare patients for missed appointments? 

 Yes, you can bill Medicare patients for missed appointments. CMS recently released Change Request 5613, which clarifies when a Medicare patient can be billed for a missed appointment. 

Medicare does not pay missed appointment fees - however, the provider may bill the Medicare patient directly as long as the provider also charges non-Medicare patients for missed appointments. The charged amount must be the same for both Medicare and non-Medicare patients. 

Claims for missed appointments sent to Medicare will be denied with the reason code 204: This service/ equipment/drug is not covered under the patient’s current benefit plan. In most instances, a hospital patient department can charge a beneficiary a missed appointment charge. However, if a hospital inpatient misses an appointment in the hospital outpatient department, the outpatient department may not charge the patient a missed appointment fee. 

Read CR5613 for complete details and to access the updated Medicare Claims Processing Manual section 30.3.13 Charges for Missed Appointments.

 I am interested in participating in the Medicare Physician Quality Reporting Initiative (PQRI), but I have three questions: How much bonus can I expect to receive if I successfully report? Is it too late to start the program for 2008? If I don’t meet the performance measures will there be punitive action? 

 Good questions. Let’s take them one by one: First, it isn’t possible to determine exactly how much bonus you would receive if you successfully met the reporting guidelines. As was true in 2007, you can earn a bonus payment of 1.5 percent of the total allowed charges for covered Medicare physician fee schedule services (services paid under the Medicare Physician Fee Schedule), subject to a cap. 

The bonus cap is calculated as follows: (the individual’s instances of reporting quality data) multiplied by (300 percent) multiplied by (the national average per measure payment (NAPMP)). The NAPMP is: (the total amount of allowed charges under the Physician Fee Schedule for all covered professional services furnished during the reporting period on claims for which quality measures were reported by all participants in the program) divided by (the total number of instances where data were reported by all participants in the program for all measures during the reporting period). 

Because the bonus cap calculation can’t be determined until after the 2008 PQRI, the best you can do is calculate your expected Medicare payments for services paid under the Medicare Physician Fee Schedule (this excludes drugs and labs) and multiply that by 1.5 percent for an approximate bonus payment amount. 

As for timing, if you begin reporting now and you report on enough measures and report on them virtually every time they are reportable, you may still be able to meet the reporting threshold. The 2008 PQRI reporting period runs from Jan. 1, 2008 through Dec. 31, 2008. 

Finally, the PQRI is a “pay-for-reporting” program, not a “pay-for-performance” program. CMS reports that there will be no punitive action for not meeting performance measures. However, the PQRI reports may be made public. 

The AMA has available tools designed to aid in the identification of Quality Measures relevant to your practice and to facilitate the data collection required to report clinical performance data. The following documents are available for each Quality Measure: 

 An informational sheet is available for each measure in the PQRI program. This document contains additional descriptive information regarding the measure and should help users determine if it is a measure on which they would like to report. In particular, the document describes what type of information is required to report on the measure and how frequently reporting is required.

 A data collection sheet is provided for each measure in the PQRI program. This document is a step-by-step tool for clinical use and office/billing staff use. It allows the physician or other eligible professional to record the clinical information required for the measure by checking the appropriate box, and the coder to subsequently select the corresponding billing code.

 A coding specifications sheet is available that includes a complete list of ICD-9 and CPT codes to identify patients eligible for the measure. A list of the quality codes for each measure is also included. The coding specifications document is to be used in conjunction with the data collection sheet to determine the appropriate code or combination of codes to be reported.

is this issue’s expert. Cleland provides educational programs through national speaking engagements and oncology publications. She is the founder and president of Oplinc, Inc. She also works as a consultant and adviser for physician practices, pharmaceutical companies, and distributors. She can be reached at 

This article originally appeared in the April 2008 issue of

 Your Best Practice: A Practice Management Supplement for Oncologists and Hematologists 

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Oncology practice-management expert Risë Marie Cleland answers your most common questions.

Ask the Experts: Your Top Questions Answered


Surely, your oncology practice remembers this well: 

When the Medicare Modernization Act of 2003 was signed into law, the reimbursement rate for Part B drugs dropped from 95 percent of Average Wholesale Price (AWP) to 85 percent. And who could forget how, with the transition to the new Average Sales Price (ASP) payment methodology in 2005, Part B drug reimbursement further declined for most drugs? 

Granted, you enjoyed a passing bit of relief when Medicare established its 2005 Demonstration of Improved Quality of Care for Cancer Patients and 2006 Oncology Demonstration Project - both of which provided a temporary source of new revenues for participating practices, thereby offsetting the reduction in drug payments. Still, what a major impact all this has caused, especially if you consider that drug revenues account for approximately 70 percent of total revenue in medical oncology. 

What’s more, this continued focus on the difference between physicians’ cost for drugs and the reimbursement rate has resulted in a steady increase of private payers moving to an ASP payment methodology - a trend that is expected to continue. This means that margins on physician-administered drugs will continue to decline as more payers move to ASP. 

Sounds very discouraging. But, believe it or not, you can improve your bottom line by improving your business operations through simple work flow and technology solutions. Read on for some strategies to achieve this. 

Many claim denials are due to inaccurate patient demographics, so it’s critically important that you keep your patients’ demographic information current. Note that these inaccuracies occur surreptitiously, such as when a patient moves across town or changes his phone number and he forgets to tell you. Life goes on, but your claims won’t if you don’t keep on top of these sorts of changes. 

Do you have a review process in place for keeping patient demographics and insurance information current? If not, establish one. With the high cost of new cancer therapies, many oncology practices are now verifying insurance information before every treatment. At a bare minimum, the information should be completely updated every three months. To minimize errors, limit the number of staff members who can initiate changes in an existing patient’s demographics. Also, identify specific staff members who should be notified of any changes made, in order to reduce billing/collection problems. 

But what about uninsured/underinsured patients? How will you handle them? Will you treat these patients in the office? If yes, then decide on a financial liability limit that feels appropriate for your practice. Or will you limit indigent care? Establish a policy that determines how much charitable care the practice can afford, apply it, and then monitor it. 


The importance of accurate charge capture can’t be overstated: You can’t get paid if you don’t bill for a service. Lost charges can occur when a service is not captured on the charge ticket, when the service is incorrectly entered on the charge ticket (wrong units, etc.), or the charge ticket itself goes missing. In essence, you’ve done the work for free, and who can afford to do that (except for planned charity care, of course)? 

Just as in obsolete patient demographics, the losses can really add up. Consider that $200 lost every day from unbilled services for just one physician calculates to about $50,000 annually. Nothing will guard your oncology practice against such lost charges more than having processes and systems in place. 

One way to lose charges is to lose the charge ticket itself. Charge tickets that are part of an EMR are less likely to be “lost,” but they’re subject to late billing if not signed off on in a timely manner. Paper charge tickets are easily misplaced and often never make their way back to the billing department. 

Use your practice management and billing systems to help you keep track of it all: Likely, one of these systems has a built-in facility for minimizing the number of lost charge tickets, with each system-generated charge ticket assigned a distinct number. When your staff enters the charges after a patient encounter, they are posted to that distinct number. At the end of the day, generate a “missing ticket” report to flag any outstanding charge tickets. 

Even if neither of these options is available, you can still manually verify that all charge tickets have been received. Check your practice’s appointment schedule against the charge tickets to verify that there is in fact a ticket for each patient. 

You can also lose charges as a result of services either not captured or incorrectly recorded on the charge ticket. This is particularly common with drug charges. Drug inventory cabinets, such as the Pyxis system, offer functionality that will help your practice capture all drug charges, automate billing, and control and maintain inventory management. This system will print a daily transaction log that includes for each patient the drug administered and the drug wasted (when appropriate). You can then compare this report with the drugs marked on the charge ticket (or entered in the electronic billing record) to ensure that all drugs administered were billed properly. 

Prior to sending claims out, run a report to make sure that all drugs were billed with the proper units attached. For even easier review, export the report to an Excel spreadsheet and then sort it by J-code. Many drugs have standard doses so it’s fairly easy to see if the units were incorrectly billed. For example, consider the antiemetic drug Aloxi, which has a billing code of J2469, a billing unit of 25 mcg., and a standard dose of 0.25 mg. Therefore, Aloxi should be billed at 10 units of J2469. 

Proper coding and billing for services is undoubtedly the surest way to reduce denials and underpayments. For drugs/fluids and their administration you must know: 

 - hydration, therapeutic, or chemotherapy drugs; 

 - sequential or concurrent (Note: Piggy-backed drugs must be in separate bags to be billed concurrently); and 


Also, make sure you understand the billing rules and regulations for Medicare and private payers. Medicare information is on the Centers for Medicare and Medicaid Services (CMS) Web site and your local Medicare contractor’s Web site. Because these rules are publicly available, most practice management and billing programs contain built-in edits or claim scrubbers based on Medicare rules. Edit programs that are updated regularly for LCD, NCD, CCI, and code and modifier changes can be useful in identifying potential billing errors, such as bundled services, services requiring additional diagnoses, or modifiers. 

And what about your private payers? Check each one. Some follow the NCCI edit guidelines. Others use third-party proprietary claims edit programs. Most private payers, however, do not explicitly specify the source or logic behind their claims editing program and process. 

Hopefully, your private payer claims are adjudicated based on the AMA’s Current Procedural Terminology (CPT) guidelines and conventions. CPT codes are a HIPAA-designated code set by which you can bill and get reimbursed properly for the services you provided. The AMA develops and maintains the CPT codes, modifiers, instructions, and guidelines, with input from physicians, third-party payers, and government agencies. You can purchase the CPT codes, guidelines, and conventions listed above from the AMA for a nominal fee. 

Recent class-action lawsuits filed by the AMA on behalf of physician groups against payers alleging improper bundling and downcoding, and rejecting correctly used modifiers have been successful in changing some payers’ inappropriate claims edits. Still, private payers continue to expand their claims audits and reviews, so your best defense is to have negotiated in the contract proper claim adjudication based on the AMA CPT guidelines, and then adhere to those rules when billing for services and procedures. 

But all these rules and regulations are worthless if nobody in your practice knows when - not if - they change. Therefore: 

Have your billing manager establish and enforce a practice-wide communications protocol

 that ensures that everyone involved in billing and collecting receives all updates on billing rules and regulations in a timely manner.

 to address specific billing and reimbursement problems, and to track progress on earlier identified issues.

Make sure your billing staff reads the newsletters

 put out by your Medicare contractor as well as all private payer/provider bulletins and newsletters.

To increase the odds that your claims will be accepted the first time around, consider giving them a spit-shine with claim-scrubber software. But before purchasing or using a claims edit program, verify what the software is basing the scrubbing and coding analysis on. Medicare edits? AMA CPT guidelines? 

Some other third-party claims edit product? Ideally, the claim-scrubber software will contain Medicare edits and the AMA CPT guidelines, and it will apply the edits based on the particular patient’s primary payer. 

Other considerations when choosing a claim scrubber: 

. Choose a program that is currently in use in your specialty;

2. Look for a program that includes edit guidance

 with links to supporting documents (i.e., NCDs, LCDs, CCI edits, etc.). 

3. Make sure you can get adequate initial and ongoing training;

 an unused or misused program is a waste of money. 

4. Make sure the vendor updates and improves the product regularly

5. Give preference to software that can be automatically updated via the Internet

 - it’s usually more accurate, with updates that are less disruptive to the practice. 


Most practice management systems will allow you to enter your expected payment. Therefore, loading contracted fee schedules into your software program should be a priority. While it can be challenging to get the complete fee schedules from payers, they are obligated to provide them. Furthermore, without the payers’ fee schedules (or reimbursement methodology), you won’t know what you have agreed to contractually, and you won’t know if you are being paid correctly. 

Rank your payers according to volume and keep their information up to date, so you always know whether you’re being reimbursed according to your contract. The AMA reports that challenging inappropriate claims payments may lead to a positive change in the health plan’s business practices. And, by loading fee schedules into your system, you can also determine a very good benchmark for collections. 

Make sure that the fee schedules are routinely updated. This takes little time once the figures are first entered, as most payers update their fee schedules quarterly, or even less often. Be aware that “bundling” issues will mean that some of the expected payment amounts associated with certain line items won’t be collectible. Nevertheless, you will have a good indicator of what should be collected. 

Web-based reimbursement technology is gaining in popularity; RemitDATA is one such program. RemitDATA’s Reimbursement Pro uploads the Electronic Remittance Notices or Advices (ERNs or ERAs), ANSI-835 files from Medicare, Medicaid, and commercial payers into a secure Web account. You can then log into your account to retrieve your reports, which are numerous. 

RemitDATA, for example, offers a claim summary by reason code and procedure. This report includes the procedures denied and the reason codes for the denials, allowing you to track which procedures are being denied, the frequency of the denials, and the reasons for the denials. 

This is information that is often not accurately captured in our practice management systems, as most software programs default to a contractual write-off and it is up to the individual entering the data to choose the correct denial or write-off code (often not done). With RemitDATA, the information comes directly from the ANSI-835 file so the denial reason code is accurate with the Explanation of Benefits (EOB). 

This information has real value: When you are able to accurately capture denial types and frequency, you can pinpoint actions to take to reduce future denials. 

Other benchmarking reports offered by RemitDATA will allow you to compare your practice to other oncology practices so you can see how your collections and denials compare nationally (within RemitDATA’s clientele). 

Finally, respond swiftly to requests for supporting documentation, denials, underpayments, and nonpayments. The Medical Group Management Association reports that the best performing practices have dedicated staff to handle these issues. If your practice lacks dedicated claims-follow-up staff, you may be putting yourself at risk of missing deadlines for submitting requested documentation and appealing denials and underpayments. 

Getting paid fairly and completely is no small task these days. Stay informed and ever-vigilant of changes, and collect, collect, collect. 

Cleland provides educational programs through national speaking engagements and oncology publications. She is the founder and president of Oplinc, Inc. She also works as a consultant and adviser for physician practices, pharmaceutical companies, and distributors. Contact her at 

This article originally appeared in the April 2008 issue of Your Best Practice: A Practice Management Supplement for Oncologists and Hematologists. 


You work hard to provide high-quality service, but billing and collecting for your work is getting harder than ever. Here’s a primer on the technology tools that can help.

Author | Risë Marie Cleland

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