Can Billing This Way Be Right?

Rebecca Bechhold, MD

Having worked for many years within a large, private office–based group offering comprehensive oncology care, when I recently spoke with someone working at a hospital-based oncology clinic in another state, I was alarmed by the way their practice is structured.

In that practice, the patient is never treated on the day they see the doctor. I am told by others that this is standard. That means patients make at least two trips for every treatment. One to see the doctor-co-pay required, evaluation and management (E&M) charged, lab drawn. Then the patients return another day for treatment-another co-pay, facility charge, administration and drug charges, and repeat labs. If they need granulocyte-colony stimulating factor or a pump removal, they may return yet another day.

In the private office–based group, seeing patients the day of treatment is the norm. Patients are typically charged an E&M code to cover chemotherapy management plus administration and drug charges. It would never occur to me to see the patient on a different day. I need to know how they are doing on the day I prescribe the treatment. How they felt a week ago is only partly relevant.

The explanation is that the facility can bill more if the patient comes on separate days. The billing department worries that using modifier 25 in order to add an E&M charge the same day as chemotherapy will bring unwanted attention.

They may be absolutely correct, but I still contend that most patients should see the oncologist within 24 hours of receiving chemotherapy. Obviously there are scenarios where the patient may not need direct contact with every single dose (think maintenance trastuzumab). But with separate appointments there can also be instances where a patient is “lost”-I know of one patient, for example, who completed 4 cycles of A/C without seeing a doctor. This seems horribly wrong to me on many levels.

I am not trying to micromanage, but most of the time I want to lay eyes on and talk to my patient. Equally concerning to me is the fact that the patient has to travel or find transportation for multiple visits, have repetitive lab work, and pay additional co-pays.

What about patients on weekly treatment? They would be in the office more often than not. Do they get a nearby hotel room?

I write this to ask readers, both staff and patients, to offer their take on this.

Is this just one more way our healthcare system is poorly constructed? Is this a standard and I am just hopelessly out of touch?  If it is the standard, is it fair? Is it best practice? Should we be changing this?

Cancer treatment is enough of a burden. I try to make it as easy logistically as I can, and I certainly try to be honest and thoughtful regarding the financial toxicity. Our patients have trust in us; we must provide care in the most ethical manner. Call me crazy, but this setup just seems wrong.