Expert Oncology Medical Billing & RCM Services
Specialized revenue cycle management for cancer treatment practices. Maximize reimbursements for chemotherapy administration, radiation oncology, and complex cancer care with our expert billing solutions.
Oncology Billing Challenges We Solve
Cancer treatment billing requires specialized expertise in chemotherapy administration, radiation therapy, and complex oncology procedures.
Chemotherapy Administration Coding
Chemotherapy billing requires precise documentation of infusion time, concurrent vs sequential administration, push vs infusion techniques, and drug-specific coding. Each agent must be coded separately with appropriate administration codes, and mixing multiple drugs requires careful sequencing and modifier application.
Revenue Impact:
Improper chemotherapy coding results in 20-30% revenue loss and frequent payer audits
Radiation Oncology Technical Components
Radiation therapy involves complex planning, simulation, treatment delivery, and management services that span weeks or months. Proper billing requires tracking treatment management codes, distinguishing professional vs technical components, and coordinating IMRT, IGRT, and special procedures billing across the care continuum.
Revenue Impact:
Revenue leakage of $50,000-$150,000 annually from missed technical components and treatment management codes
E/M Complexity and Time-Based Coding
Oncology encounters frequently exceed typical visit times due to treatment discussions, clinical decision-making, and coordination of care. New prolonged service codes and time-based E/M documentation allow capture of this complexity, but require meticulous time tracking and medical necessity documentation.
Revenue Impact:
Practices lose $80,000-$200,000 annually by not utilizing prolonged service codes and appropriate E/M levels
Clinical Trial Billing Coordination
When patients participate in clinical trials, determining what services are billable to insurance vs covered by the trial sponsor requires detailed protocol review and coordination. Standard of care services remain billable while investigational procedures must be separated, requiring sophisticated tracking and documentation.
Revenue Impact:
Billing errors cost practices $30,000-$80,000 per trial in denied claims or sponsor disputes
Drug Supply and J-Code Management
Oncology practices manage expensive specialty drugs requiring proper J-code billing, buy-and-bill tracking, and coordination with specialty pharmacies. Accurate unit calculation, waste documentation, and timely submission are critical for cash flow given the high drug costs ($10,000-$100,000+ per treatment).
Revenue Impact:
Drug billing errors and delays create $200,000-$500,000 in cash flow disruption and potential write-offs
Pathology and Laboratory Coordination
Cancer diagnosis and treatment monitoring involve extensive laboratory and pathology services including molecular testing, immunohistochemistry, and genomic profiling. Coordinating between in-house labs, reference labs, and pathology services while ensuring proper ordering provider documentation and medical necessity requires sophisticated systems.
Revenue Impact:
Lab billing coordination gaps result in 10-15% of pathology charges becoming uncollectible
Oncology Service Categories We Optimize
Comprehensive billing expertise across all cancer treatment service lines
Chemotherapy Administration
Comprehensive infusion therapy billing including initial infusion, concurrent therapy, sequential drugs, hydration, and push techniques
Common Codes
96413, 96415, 96417, 96409, 96411
Avg. Reimbursement
$350-$1,200 per session
Frequency
Multiple sessions per treatment cycle
Radiation Oncology Services
Complete radiation therapy cycle from simulation through treatment delivery and management including IMRT, IGRT, and special procedures
Common Codes
77014, 77385, 77427, 77301, 77295
Avg. Reimbursement
$15,000-$45,000 per treatment course
Frequency
6-8 week treatment courses
Surgical Oncology Procedures
Tumor resection, lymph node dissection, reconstructive procedures, and oncologic surgical procedures
Common Codes
19301, 38525, 38571, 49203, 32440
Avg. Reimbursement
$2,500-$15,000 per procedure
Frequency
1-3 procedures per patient
Diagnostic & Monitoring Services
PET/CT scans, tumor markers, pathology review, molecular diagnostics, and disease monitoring tests
Common Codes
78814, 88305, 81445, 86360, 83520
Avg. Reimbursement
$500-$5,000 per service
Frequency
Quarterly to semi-annually
Supportive Care Services
Bone marrow stimulation, antiemetic therapy, blood transfusions, pain management, and supportive infusions
Common Codes
96372, 96413, 36430, 96365, 62320
Avg. Reimbursement
$150-$800 per service
Frequency
Multiple times per treatment cycle
Our Oncology Billing Performance
Consistently outperforming industry benchmarks in cancer treatment billing
Clean Claim Rate
Our Performance
97.5%
Industry Avg.
88.2%
Chemo Administration Accuracy
Our Performance
98.8%
Industry Avg.
84.1%
Average Days to Payment
Our Performance
24 days
Industry Avg.
38 days
Drug Billing Accuracy
Our Performance
99.2%
Industry Avg.
87.5%
Denial Rate
Our Performance
1.4%
Industry Avg.
4.8%
Net Collection Rate
Our Performance
98.1%
Industry Avg.
92.3%
Oncology Practice Success Stories
Real results from cancer treatment practices using our specialized billing services
Multi-Site Radiation Oncology Practice
Radiation Oncology & Medical Oncology
Challenge
A 4-location radiation oncology practice was experiencing significant revenue leakage from incomplete treatment management billing, missing technical component charges, and poor IMRT/IGRT documentation. Their clean claim rate was 84% with frequent denials on complex radiation procedures.
Solution
Implemented comprehensive radiation therapy billing protocols including automated treatment management tracking, technical/professional component separation systems, and specialized IMRT/IGRT documentation workflows. Created integrated chemotherapy administration protocols for medical oncology services. Deployed radiation-specific claim scrubbing and weekly charge reconciliation.
Results Achieved
Community Cancer Center
Medical Oncology & Hematology
Challenge
An independent community cancer center was struggling with chemotherapy administration coding complexity, managing buy-and-bill drug inventory, and coordinating clinical trial billing. They experienced frequent J-code denials and cash flow challenges from $300,000+ monthly drug purchases.
Solution
Implemented specialized oncology billing software integrated with their EMR to track infusion start/stop times, drug units, and sequential vs concurrent administration. Created buy-and-bill tracking system with automated J-code assignment and waste documentation. Established clinical trial billing protocols with protocol coverage analysis and research coordination.
Results Achieved
Academic Oncology Program
Surgical Oncology, Radiation, Medical Oncology
Challenge
A university-affiliated comprehensive cancer center with surgical, medical, and radiation oncology divisions had fragmented billing operations, inconsistent E/M coding, and poor capture of complex procedures and pathology services. Multiple specialties led to coordination challenges and 6.5% denial rate.
Solution
Unified billing operations across all oncology divisions with specialty-specific coding teams. Implemented time-based E/M documentation templates and prolonged service workflows. Created tumor board and multidisciplinary conference billing protocols. Established pathology and molecular diagnostics coordination with reference labs.
Results Achieved
Why Oncology Practices Choose Healix RCM
Specialized expertise that delivers measurable results for cancer treatment billing
Oncology Specialists
Certified coders with specialized oncology training and deep expertise in chemotherapy, radiation, and cancer surgery billing
Revenue Optimization
Maximize reimbursement through proper sequencing, time-based coding, and comprehensive capture of all billable services
Faster Payments
Average 24-day payment cycle with 97.5% clean claim rate reduces cash flow stress from high drug costs
Compliance Expertise
Stay compliant with chemotherapy administration rules, radiation bundling guidelines, and clinical trial billing regulations
Technology Integration
EMR-integrated solutions for real-time infusion tracking, automated J-code assignment, and buy-and-bill management
Proven Results
Track record of increasing oncology practice revenue by 15-35% through comprehensive billing optimization
Frequently Asked Questions
Common questions about oncology medical billing and our services
How do you handle chemotherapy administration billing with multiple drugs?
We manage complex chemotherapy administration billing by tracking infusion start/stop times for each drug, properly sequencing initial vs subsequent codes (96413, 96415), distinguishing concurrent vs sequential administration, and applying appropriate push technique codes (96417, 96409). Our EMR-integrated system captures real-time administration data and automatically assigns correct CPT codes based on timing, sequencing, and administration method. We ensure proper modifier usage and documentation to support medical necessity and prevent bundling denials.
What makes radiation oncology billing so complex?
Radiation oncology billing spans weeks to months and involves multiple components: simulation/planning (77014, 77295), treatment planning (77301, 77385 for IMRT), daily treatment delivery, and weekly treatment management codes (77427, 77431, 77432). Complexity comes from tracking professional vs technical components, coordinating between radiation oncologists and medical physicists, documenting special procedures like IGRT, and ensuring all planning, delivery, and management services are captured throughout the multi-week treatment course. We use specialized tracking systems to ensure complete billing.
How do you maximize E/M reimbursement for complex oncology visits?
Oncology encounters often involve extensive counseling, treatment discussions, and care coordination that justify high-level E/M codes and prolonged services. We implement time-based documentation workflows that capture total visit time, counsel patients on documentation requirements, and utilize prolonged service codes (99417) when visits exceed threshold times. Our coding team reviews medical decision-making complexity, number of diagnoses managed, data reviewed, and risk level to ensure appropriate E/M level assignment (typically 99214-99215 for established patients, 99204-99205 for new patients).
How do you handle billing when patients are in clinical trials?
Clinical trial billing requires detailed protocol coverage analysis to determine which services are standard of care (billable to insurance) vs investigational (sponsored by trial). We review each trial protocol, create coverage analysis documents, and implement tracking systems that flag trial patients and separate billable from non-billable services. Our team coordinates with research coordinators to ensure proper documentation, submits only appropriate charges to insurance, and maintains audit trails. This prevents both improper billing to payers and missed revenue from billable standard care services.
What is buy-and-bill and how do you optimize drug reimbursement?
Buy-and-bill refers to practices purchasing expensive specialty drugs and seeking reimbursement after administration. We optimize this by: 1) Implementing precise J-code assignment based on drug and dosage, 2) Calculating exact units administered and documenting waste with JW modifier, 3) Ensuring timely claim submission to minimize cash flow gap, 4) Tracking drug costs vs reimbursement to identify unfavorable contracts, and 5) Coordinating with specialty pharmacies when appropriate. Our systems help practices manage $200,000-$500,000+ in monthly drug inventory while maintaining positive cash flow.
How do you handle pathology and molecular diagnostic billing?
We coordinate pathology billing by ensuring proper ordering provider documentation, medical necessity for complex testing, and coordination between in-house and reference laboratories. For surgical pathology (88305, 88307), we verify specimen documentation and complexity levels. For molecular diagnostics (81445, 81247, etc.), we confirm coverage policies, obtain prior authorization when required, and provide comprehensive clinical documentation. We track send-out specimens to reference labs and ensure charges are coordinated to prevent duplicate billing while maximizing collectibility for these high-value services.
What denial management strategies work best for oncology practices?
Oncology denials often involve medical necessity questions, chemotherapy administration sequencing disputes, radiation therapy bundling issues, and drug coverage denials. Our denial management includes: 1) Specialty-trained appeal writers who understand oncology clinical rationale, 2) Quick-response systems for same-day resubmission of technical denials, 3) Peer-to-peer appeal coordination with medical directors, 4) Comprehensive clinical documentation including treatment protocols and NCCN guidelines, and 5) Proactive prior authorization for high-value services. We maintain detailed denial tracking by payer and code to identify systemic issues and prevent future denials.
How do you ensure compliance with oncology billing regulations?
Oncology billing compliance requires adherence to chemotherapy administration guidelines, radiation oncology CPT bundling rules, drug wastage documentation requirements, and clinical trial billing regulations. We maintain compliance through: 1) Regular NCCN and CMS guideline reviews, 2) Automated claim scrubbing for oncology-specific edits, 3) Documentation audit programs focusing on time-based services and medical necessity, 4) Staff training on chemotherapy sequencing rules and radiation component billing, and 5) Monitoring OIG work plans and payer policy updates. Our compliance program includes quarterly internal audits and annual external compliance reviews.
Ready to Optimize Your Oncology Practice Revenue?
Partner with oncology billing specialists who understand chemotherapy administration, radiation therapy, and complex cancer care billing.