Do you use Athenahealth for oncology billing daily? Are revenue leaks hurting your cancer practice profits? Studies show oncology practices lose 15-20% revenue from billing errors. Complex chemotherapy coding causes 35% of claim denials annually. About 70% of oncology claims need prior authorization requirements. Drug reimbursement errors cost practices an average of $200,000 per year. A proper Athenahealth setup can reduce denials by 60% quickly.
Oncology billing is one of the most complex specialties. Cancer treatment involves chemotherapy, radiation, and multiple procedures daily. Athenahealth offers powerful tools for oncology revenue cycle management. Many practices don’t use all available features correctly, though. Misconfigured settings cause claim denials and payment delays. Understanding system capabilities helps maximize practice revenue significantly.
This guide identifies major oncology billing risks in Athenahealth. We show practical fixes for each common problem. Learn how to configure settings correctly for better results. Improve your clean claim rate starting today easily. Reduce denials and speed up payment cycles now. These solutions work for cancer practices of all sizes.
Chemotherapy Coding and Drug Billing Risks
Chemo drug billing is complex and error-prone. Wrong codes cause automatic claim denials. Proper drug coding prevents most payment problems.
J-Code Selection Errors
J-codes identify specific chemo drugs for billing. Each drug has a unique code and dosage. Wrong J-code causes claim rejection immediately. Athenahealth’s drug library must be current. Update drug codes quarterly when changes occur. Link J-codes to NDC numbers correctly. Missing updates lead to denials and delays.
Unit of Measure Problems
Drugs bill by different units. Some use milligrams, others use units. Wrong unit calculation causes underpayment or denial. Athenahealth calculates units automatically if configured. Set up a drug library with correct units. Train staff on unit conversion rules. Double-check calculations before claim submission occurs.
Buy and Bill Documentation
Document the actual drug cost and invoice. Link drug lot numbers to the patient. Keep purchase receipts for audit proof. Athenahealth can store invoice data. Upload documents to the patient’s chart. Missing docs cause reimbursement problems later. Auditors request proof of purchase often.
Prior Authorization Management Issues
Prior authorization is required for most cancer treatments. Missing auth causes automatic claim denials.
Workflow Configuration Problems
Set up auth tracking in Athenahealth. Enable alerts for expiring auths always. Configure staff tasks for auth follow-up. Missing workflow causes auth lapses and denials. Assign specific staff to auth management. Create standardized auth request templates today. Regular monitoring prevents coverage gaps completely.
Authorization Expiration Tracking
Track the auth start and end dates. Set reminders before expiration always. Submit renewal requests two weeks early. The Athenahealth calendar shows the auth status clearly. Late renewals cause treatment delays and denials. Document all auth communications in the system. Expired auths stop payments immediately, always.
Clinical Documentation Requirements
Include staging and diagnosis details clearly. Document treatment plan and medical necessity. Attach pathology and lab reports always. Athenahealth allows document attachment to auths. Complete clinical notes support auth approval. Insufficient docs cause auth denials frequently. Review denial reasons and add missing info.
Modifier Usage and Coding Errors
Modifiers provide important claim information to payers. Wrong or missing modifiers cause payment problems.
Missing Critical Modifiers
Modifier 59 shows distinct procedural services. Modifier 25 indicates a significant separate E/M. Modifier JW reports drug wastage amounts. Configure Athenahealth to prompt for modifiers. Train staff on modifier requirements daily. Missing modifiers result in claim bundling. Regular audits catch modifier errors early.
Inappropriate Modifier Combinations
Some modifiers cannot be used together. RT and LT show right and left. Cannot use both on the same line. Athenahealth edits catch some conflicts. Configure edit checks for your specialty. Review claims before submission always occurs. Conflicting modifiers cause automatic claim rejections.
Drug Wastage Reporting
Report unused drug amounts with the JW modifier. Calculate wastage from the vial size minus the dose. Document wastage in patient chart notes. Athenahealth can calculate wastage automatically if configured. Missing wastage reports lose reimbursement money. Keep vial labels and lot numbers.
Place of Service Code Problems
POS codes identify where treatment occurred. Wrong POS code causes claim denials. Athenahealth defaults may not match reality.
Office vs Facility Billing
Office setting uses the POS 11 code. Hospital outpatient uses the POS 22 code. Reimbursement rates differ by location setting. Athenahealth must match the actual treatment location. Configure the default POS for each provider. Review and update POS codes regularly. Wrong POS causes payment denials always.
Infusion Center Configuration
Infusion centers may use different POS. Check payer policies for correct codes. Some payers have special POS requirements. Configure Athenahealth for your specific setting. Train schedulers on correct POS selection. Document the actual location in the patient notes. Inconsistent POS codes trigger claim reviews.
Home Health Service Coding
Home infusions use the POS 12 code. Different rates apply for home services. Documentation proves that service location is always required. Athenahealth allows custom POS setup. Create encounter templates for home visits. Include travel and setup time codes. Missing location docs cause audit problems.
Time-Based Billing Inaccuracies
Many oncology services bill by time. Wrong time documentation causes payment problems. Athenahealth time tracking helps if used.
Infusion Time Calculation
Initial infusion codes require 16+ minutes. Subsequent infusions need different time thresholds. Calculate total infusion time accurately, always. Athenahealth can auto-calculate if times are entered. Document start and stop times clearly. Include prep and cleanup time allowed. Wrong times lead to code downgrades.
Concurrent vs Sequential Coding
Concurrent infusions happen at the same time. Sequential infusions happen one after another. Codes differ based on the timing sequence. Athenahealth workflow should capture timing clearly. Train nurses on documentation requirements daily. Review infusion logs before billing occurs.
Hydration and Push Administration
Hydration bills differently than chemo drugs. IV push has specific time requirements. Cannot bill hydration with chemo usually. Configure Athenahealth with payer-specific rules. Create alerts for common billing conflicts. Review claims for inappropriate bundling issues. Payer policies vary for hydration billing.
Technology Configuration and Setup Fixes
A proper Athenahealth setup prevents most billing errors. Default settings may not work for oncology. Custom configuration improves claim success rates.
Drug Library Maintenance
Update drug library quarterly with new codes. Link J-codes to NDC numbers correctly. Set correct units of measure for drugs. Configure average wholesale price data accurately. Enable drug interaction alerts for safety. Document drug administration routes and methods. The current library prevents coding errors completely.
Custom Edit Checks
Create edits for common oncology errors. Check for missing modifiers before submission. Verify prior auth numbers are present. Alert for inappropriate code combinations always. Configure diagnosis to procedure edits properly. Test edits with sample claims first. Custom edits reduce denials by 40%.
Reporting and Analytics Tools
Run denial reports weekly for patterns. Track clean claim rates by provider. Monitor days in accounts receivable closely. Identify the top denial reasons for training. Use Athenahealth dashboards for real-time data. Generate revenue cycle performance reports monthly. Data-driven decisions improve billing outcomes significantly.
Conclusion
Athenahealth offers powerful oncology billing tools when configured correctly. Chemo drug coding and prior authorization management pose the biggest risks. Modifier usage and place of service errors cause denials. Time-based billing requires accurate documentation always throughout. Proper system setup and staff training prevent errors. Regular audits and reporting identify problems early.
FAQs
What is the most common oncology billing error in Athenahealth?
Wrong J-code selection for chemotherapy drugs causes most denials. The drug library must be updated quarterly with changes. Link J-codes to NDC numbers correctly always.
How often should I update the Athenahealth drug library?
Update the rug library every quarter when codes change. New drugs are released throughout the year regularly. Check CMS updates for J-code changes monthly.
Can Athenahealth automatically calculate drug wastage?
Yes, if configured correctly with drug library data. Enter vial size and actual dose given. The system calculates the wastage amount automatically. Must use the JW modifier for wastage claims.
What modifiers are most important for oncology billing?
Modifier 59 for distinct services is critical. Modifier JW reports drug wastage for payment. Modifier 25 for significant separate E/M visits. Configure Athenahealth to prompt for required modifiers.
How can I reduce prior authorization denials?
Set up the auth tracking workflow in Athenahealth. Enable expiration alerts two weeks before the end. Assign dedicated staff to auth management tasks.
