Healthcare continues to move rapidly toward the direction of more collaborative care, with patient care being coordinated among specialties and anchored by a primary care provider. The pace of this change, however, does not minimize the opportunity to improve key workflows, especially in the area of imaging.
Every oncology patient will at some point in their course of treatment require imaging services. As such, the workflow between an oncology practice and an imaging center or facility, and the accurate documentation of medication necessity, has a significant impact on 2 elements of value to every practice: time and patient satisfaction.
First, every practice values time. The patient encounter is a well-tuned process. Every effort is made to reduce additional phone calls for administrative tasks. But take a quick poll: how many times in a given day does the imaging center, or billing office for the imaging center, reach out to your clinical staff for more information? How often is a request made for a new or revised order? How often is any other communication made that disrupts that well-tuned process?
Second, every practice values patient satisfaction. One quick path to dissatisfaction is delayed or denied insurance claims, resulting in even higher balances on patient accounts. When patients are sent for imaging studies that are essential to their treatment plan, they trust that the communication between your practice and the imaging center will address what the insurance company needs to process and pay the claim.
How are claims processing or charge capture challenges of the imaging facility your problem? After all, these stumbling blocks likely will not affect whether you get paid for your services. They will, however, affect a key component, and true focus, of your practice: the patient. Denial letters from insurance companies are stressful. Statements for past-due imaging charges are stressful. Delays in preauthorization or denied authorizations for key imaging studies are stressful. Stressed patients usually are not satisfied patients.
What can you do to improve the process between your practice and the imaging department? Accurate communication of medical necessity is essential. Every corner of healthcare is now highlighting medical necessity, and when you clearly communicate why the imaging is needed, you improve the process for your office and your patient.
The communication tool between your practice and the imaging center is the order or requisition form. Whether this communication tool is a piece of paper or a computer screen, it is worth considering the rest of the sentence regarding a positron emission tomography (PET) and computed tomography (CT) order, “We are requesting a PET/CT because....”
A PET/CT is the perfect place to start thinking about medical necessity. The Centers for Medicare & Medicaid Services’ current coverage guidelines allow for only 3 subsequent imaging scans per cancer site. If the patient has >1 type of cancer, there is a separate 3-scan limit for each cancer. A subsequent scan is ordered by stating “restaging” or checking the box on the requisition form for “subsequent scan.” The imaging is needed because information is needed to determine the next step in a treatment course.
Think about a patient who has been treated for colon cancer. At some point in the treatment course, it is determined that the patient has also developed lung cancer. Is this scan really to determine the next step for the colon cancer? It is easy to categorize the patient with the first malignancy, and no one is questioning that the patient still has that malignancy, but this scan is ordered because an initial strategy is needed for the new lung cancer— a new initial strategy that will not, however, take away from the 3-scan limit for the colon cancer. Answering accurately for the specific scan will ensure that the patient’s benefits are appropriately applied.
Remember, subsequent scans are very different from a scan ordered after a period of watchful waiting for recurrence. They are also different than scans ordered for surveillance purposes in a patient with previously treated cancer who has no clinical evidence to suggest active disease. When the clinical indication on the order is limited to the patient’s primary cancer (eg, lung cancer, breast cancer) without sharing the rest of the story, or scans are considered to be subsequent when they really are not, 2 valuable goals—time and satisfaction—are at risk.
Consider an order requesting magnetic resonance imaging of the brain because of breast cancer. Perhaps this is the reason, but it is possible that there is another part to the story. The patient does have a primary malignancy, but is the imaging really being ordered because of a concern for metastatic disease in relation to the patient’s presenting signs and symptoms? Although you cannot assign a diagnosis to “rule out” metastatic disease, codes can be assigned for the variety of signs and symptoms (ie, headaches, blurred vision, slurred speech) that are associated with that metastasis. In that setting, the primary malignancy becomes a secondary diagnosis supporting the complexity of the case. Sharing a full clinical picture may also support the frequency at which scans may be requested (eg, because this patient has a complicated personal and family history of related cancers, and because the patient has had multiple treatment courses still without resolution).
The term “history of ” can be applied differently between a cancer center and the imaging center; the term is also reported differently to an insurance payer. A history of cancer may also, in turn, be interpreted differently by various agencies that may use an insurance database for myriad reasons (ie, research, life insurance policies, or commercial driver’s license). The patient may have a clinical history of prostate cancer, but the phrase “history of ” should only be used in an imaging requisition when (1) the primary site is excised/eradicated, (2) the primary site is no longer being treated, and (3) there is no evidence of remaining cancer at that primary site.
Unlike clinical protocols, there is no specific time frame for the cancer to be reported as “history of ” to an insurance payer. If the primary site is excised, there is no evidence of disease remaining at that site, and the patient elects to forego further treatment, the condition may be reported as “history of prostate cancer” within months of the biopsy.
Implementing the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) will also directly impact the clinical data shared between the oncology practice and the imaging center. Accurately demonstrating medical necessity for each and every order today will minimize additional phone calls between practices, as well as the delayed or denied claims, as we move toward ICD-10-CM implementation on October 1.