Case Study: Preventing Oncology Denials with Smarter Coding Practices

Customer Situation

A multi-specialty regional cancer center with a high chemotherapy infusion volume faced a major financial challenge. Despite having an in-house billing team, the center was experiencing a denial rate exceeding 20% for infusion-related claims. With a patient mix spanning private, commercial, and government insurers, the complexity of billing created significant obstacles, ultimately straining cash flow and increasing appeal backlogs.

Challenges

Our audit identified multiple root causes for the denials:

Best Practices for Sustained Coding Accuracy

Always document infusion start and end times to support prolonged services. Ensure ICD-10-CM diagnosis codes are specific and properly linked to CPT/HCPCS codes. Apply modifiers correctly (-59 for distinct services, JW for discarded amounts). Adopt claim scrubbing / pre-bill audits to prevent errors before submission. Provide ongoing coder training to keep pace with evolving CPT, J-codes, and payer rules.

• Medical Necessity Denials: Errors in linking CPT infusion codes (e.g., 96413, 96415) with the correct J-codes (e.g., J9045 for Carboplatin, J9201 for Gemcitabine) and supporting ICD-10-CM diagnosis codes.

• Documentation Gaps: Missing infusion start and end times prevented justification of prolonged infusion billing.

• Incorrect Modifier Use: Denials occurred when services like hydration infusion (CPT 96360) and chemotherapy infusion (CPT 96413) were billed on the same day without modifier -59, which clarifies distinct services.

• Reactive Workflow: The in-house team focused on appeals after denials rather than proactive prevention. No claim scrubbing system was in place to catch issues before submission.

Solution

The cancer center partnered with a specialized oncology billing company to redesign its revenue cycle management. The solution was built on accuracy, prevention, and training:

Expert Code Review & Training

• Conducted a detailed audit of top-denied claims.

• Delivered targeted training for clinical and billing staff on coding accuracy, modifier use, and documentation essentials.

Systematic Modifier Application

• Introduced consistent, rule-based application of modifiers (e.g., -59 for distinct services, JW for discarded drug amounts).

• Significantly reduced denials caused by bundled services.

Pre-Bill Audits (“Claim Scrubbing”)

• Implemented automated pre-bill audits using proprietary software to flag errors before claim submission.

• Common triggers: missing modifiers, incomplete documentation, unlinked diagnoses.

• Prevented recurring errors and reduced reliance on appeals.

Results

• Denial rate reduced by 75%+ (from over 20% to under 5%)

• Improved cash flow, with most claims paid on first submission

• Recovered significant denied revenue through proactive appeals

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