Yesterday I noted the numerous local events held June 7th in honor of National Cancer Survivor Day. I started thinking about not just those survivors but those who work tirelessly every day in the cancer fight.
Most patients diagnosed with cancer have a team of medical professionals: surgeons, medical oncologists, radiation oncologists, etc.
Scientific research and clinical trials champion advancements in treatment and increase cure rates and quality of life for patients.
Private physicians wishing to take on the challenge of the new treatments still unfortunately require funding. Their medical billers inherit the challenge of collecting payment for these services. As new procedures come into wider use, payers can still label them “experimental” for years.
It is important for those billers to have a solid strategy in order to successfully collect for the services provided.
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Clinical trials – For practices enrolled in official clinical trials, there are certain claim filing requirements they must adhere to. CMS claims must follow these criteria (see MLN-Matters® Number MM8401 at www.cms.gov):
The 8-digit clinical trial number preceded by the 2 alpha characters of CT must be placed in Field 19 of the paper claim Form CMS-1500 (e.g., CT12345678).
The 8-digit number on the electronic claim 837P file is contained in Loop 2300 REF02 (REF01=P4) (e.g., 12345678).
The clinical trial claim includesICD-9 code ofV70.7/ICD-10 code Z00.6 (in either the primary or secondary positions) and Modifier Q0 and/or Q1, as appropriate (outpatient claims only).
Experimental procedures – For practices utilizing cutting edge technologies, preparation is key:
Acquire statistical clinical data that helps to support the medical necessity for the procedure. This information is crucial when obtaining pre-approvals or post-denial appeals.
Research all of your payers’ medical policies for the procedure and communicate them with the treating physician. The patient’s medical record should contain all the indicators for the procedure and the medical justifications.
Be aware of payer’s pre-authorization requirements and procedures.
