How to Reduce Claim Denials in Oncology Practices

How to Reduce Claim Denials in Oncology Practices

Unfortunately, claim denials are a common and costly challenge. From complex chemotherapy coding to medication administration reporting and prior authorization issues, the risk of denials is significantly higher in oncology.

This comprehensive guide outlines practical steps to reduce claim denials in oncology practices—with a strong focus on clinical documentation, accurate coding (including CPT code 96372), payer compliance, and the role of professional oncology billing services.

Table of Contents

1. Introduction: The Impact of Claim Denials in Oncology

2. Top Reasons for Oncology Claim Denials

3. Understanding Payer Policies and Guidelines

4. Role of CPT Code 96372 in Oncology Billing

5. The Importance of Prior Authorizations

6. Enhancing Documentation Accuracy

7. Using Oncology-Specific Billing Software

8. Regular Coding and Compliance Training

9. Leveraging Oncology Billing Services

10. Audits, Feedback, and Denial Analysis

11. How to Build a Denial Prevention Strategy

12. Final Thoughts and Actionable Tips

1. Introduction: The Impact of Claim Denials in Oncology

Claim denials do more than delay payments—they jeopardize a practice’s ability to deliver high-quality care. Oncology is particularly vulnerable because:

• Treatments are high-cost and high-risk

• Billing involves complex drug rules and infusion services

• Each service often requires separate documentation and coding

• Payer policies vary widely

Reducing claim denials enhances revenue cycle management (RCM), improves patient access workflows, and empowers billing teams with the tools and training they need.

2. Top Reasons for Oncology Claim Denials

Common causes of claim denials in oncology include:

• Incorrect or missing CPT/HCPCS codes

• Invalid or vague ICD-10 codes

• Lack of prior authorization

• Incomplete documentation

• Incorrect medication units or J-code errors

• Unbundling or improper modifier usage

• Duplicate billing

• Medical necessity not established

• Omission of CPT code 96372 when applicable

• Late claim submission

Most of these denials are preventable and correctable with proactive measures.

3. Understanding Payer Policies and Guidelines

Every payer (Medicare, Medicaid, commercial insurers) has different billing rules. Staying updated with these regulations is critical.

Best Practices:

• Subscribe to payer newsletters and portals

• Assign a team member to monitor policy updates

• Maintain a payer-specific rules database

• Regularly review NCDs and LCDs

Frequent payer-specific training helps ensure compliance with CPT codes—especially those used for chemotherapy and supportive treatments.

4. Role of CPT Code 96372 in Oncology Billing

CPT Code 96372: Therapeutic, prophylactic, or diagnostic injection (subcutaneous or intramuscular)

This code is vital for supportive care in oncology, such as administering:

• Antiemetics (e.g., ondansetron)

• Growth factors (e.g., Neulasta, Procrit)

• Hormonal therapies

Common Mistakes:

• Omitting the code when supportive care is provided

• Failing to justify usage through documentation

• Not applying Modifier -59 when separating from infusion codes

Incorrect use of CPT 96372 can result in claim denials for services that were legitimately rendered.

5. The Importance of Prior Authorizations

Most oncology treatments require prior authorizations due to their cost and complexity.

Top Authorization Denial Causes:

• Incomplete documentation

• Failure to track expiration/renewal dates

• Submitting claims before approval

• Using outdated protocols

Best Practices:

• Create a dedicated prior auth team

• Use EMR-integrated tools to flag auth requirements

• Maintain a database of drug-specific payer requirements

Missed or delayed authorizations are one of the most common causes of oncology claim denials.

6. Enhancing Documentation Accuracy

Accurate documentation is the foundation of successful billing and denial prevention.

Key Documentation Must Include:

• Drug names, doses, and administration routes

• Start/stop times for infusions

• Accurate ICD-10 diagnosis codes

• Medical necessity and treatment plans

• Place of service and provider details

Ensure every CPT and HCPCS code (including 96372) is supported by thorough and specific documentation.

7. Using Oncology-Specific Billing Software

Generic billing systems may lack features required for oncology’s complexity.

Look for Systems With:

• Built-in J-code calculators for correct unit conversion

• Prior auth alerts and eligibility checks

• Oncology-focused CPT/HCPCS code libraries

• Infusion time tracking tools

• Claim scrubbing and error detection

Tools like OncoEMR, Flatiron, or CureMD Oncology can greatly reduce human error and boost claim success rates.

8. Regular Coding and Compliance Training

Staff must stay current on:

• Oncology-specific CPT and HCPCS codes

• Drug unit billing guidelines

• Modifier usage rules (-59, -25, -76, etc.)

• ICD-10 updates and NCCI edits

Training Tips:

• Conduct quarterly coding workshops

• Subscribe to AAPC or AHIMA oncology updates

• Involve providers to ensure documentation supports coding

Training builds confidence and reduces billing mistakes.

9. Leveraging Oncology Billing Services

Outsourcing your billing to oncology experts can reduce denials and increase revenue.

Benefits Include:

• Expert knowledge of oncology coding and billing

• Faster resolution of denials and appeals

• Access to coding audits and compliance support

• Dedicated account managers

• Higher clean claim rates and faster reimbursements

Billing partners often catch omissions like CPT code 96372, safeguarding your revenue.

10. Audits, Feedback, and Denial Analysis

Internal audits help identify and correct denial trends early.

Audit Focus Areas:

• Top denied CPT and J-codes

• Claims with missing documentation

• Payer-specific denial reasons

• Timely filing compliance

Tip:
Establish a monthly or quarterly denial trend report and use findings to drive training and process improvements.

11. How to Build a Denial Prevention Strategy

Step 1: Analyze Historical Denials
Review 6–12 months of past denials to find recurring patterns.

Step 2: Develop SOPs
Standardize processes for high-risk services like chemotherapy, radiation, and injections (especially CPT code 96372).

Step 3: Train and Communicate
Hold regular cross-functional sessions for billing, coding, and clinical teams.

Step 4: Implement Claim Scrubbing Tools
Use automation to flag issues like missing modifiers or unapproved drug combinations.

Step 5: Monitor KPIs
Track metrics such as:

• Claim denial rate

• Days in A/R

• First-pass acceptance rate

• Appeal success rate

12. Final Thoughts and Actionable Tips

Reducing denials isn’t just about fixing errors—it’s about building a culture of proactive compliance and data-driven decision-making.

Final Tips for Oncology Practices:

✅ Always include CPT code 96372 when applicable
✅ Never submit a claim without complete documentation
✅ Stay current with payer policies and authorization rules
✅ Use oncology-specific billing platforms
✅ Outsource complex billing to experienced partners
✅ Conduct regular audits and denial trend analysis
✅ Involve clinical staff in the billing process

By investing in the right tools, training, and partnerships, oncology practices can drastically reduce denials, protect their revenue, and focus on what truly matters—delivering exceptional care to cancer patients.