Oncology Coding Article – Outpatient Prospective Payment System (OPPS)


Medical Oncology Code Changes

Medicare Medical Necessity

In an April 2002 update to the Program Integrity Manual, CMS provided guidelines for the determination of ‘reasonable and necessary’ that indicates the service must be:

  • Safe and effective;

  • Not experimental or investigational

  • Appropriate, including the duration and frequency
    • Furnished in accordance with accepted standards of medical practice
    • Furnished in a setting appropriate to the patient’s medical needs
    • Ordered and/or furnished by qualified personnel
    • One that meets, but does not exceed, the patient’s medical need
    • At least as beneficial as an existing and available medically appropriate alternative.

    While it may seem obvious to a radiation oncologist that the patient requires IMRT or SRS treatment, medical record documentation must clearly support the necessity of providing the specific therapy for an individual patient. Practice policy, protocol or standing orders will not substitute for patient-specific chart documentation. With increasing frequency, CMS auditors are requesting the medical records that support the necessity for the type of therapy performed, as noted in physician documentation. Avoid “cloned” orders or check-off boxes and make certain that there is a specific reference to the needs of the individual patient.

    Watch for more 2005 coding changes in the upcoming months.  Review previous Coding and Reimbursement Updates from the Academy’s Website.

    This Coding and Reimbursement Update was prepared by:
    Cindy C. Parman, CPC, CPC-H
    Coding Strategies, Inc.

    Phone: (877) 6CODING

    Fax: (770) 445-0407

    [email protected]

    Cindy C. Parman, CPC, CPC-Hcparman-1286739
    principal and co-founder of Coding Strategies, Inc. in Atlanta, GA. Cindy is a current member of the Advisory Board for the American Academy of Professional Coders (AAPC) and a faculty instructor for AMA Solutions, a subsidiary of the American Medical Association.  She serves as the Consulting Editor of the Radiology Coding Alert and is on the Editorial Advisory Board of General Surgery Coding Alert and Pain Management Coding Alert.