Guidelines for Seamless Infusion Billing and Injection Therapy Services

Managing the intricacies of infusion billing has become increasingly challenging in recent times. With a wide range of infusion therapies and specialized centers, having experienced billers is essential. In fact, infusion providers risk losing over 60% of their potential revenue due to inaccurate billing practices.  

Being one of the most demanding areas in medical billing, there is no doubt that when you are billing for infusion services you need to stay alert about precise coding due to their inherent complexity. When you have skilled and knowledgeable coders handling your infusion billing correctly, half the battle is already won. 

Implementing the correct pre-billing procedures is crucial to ensuring smooth and efficient infusion billing operations. It is often seen that many get confused between codes for non-chemotherapy injections and infusions and chemotherapy administration. It can be categorized into three categories of codes in Current Procedural Terminology (CPT). 

• Hydration 
• Therapeutic, prophylactic, and diagnostic injections & infusions (excluding chemotherapy) 
• Chemotherapy administration 

Also, managing the coding essentials for infusion and injection therapy services correctly can reduce claim denials, ensure a seamless billing transaction, and expedite your reimbursement. 

Things to Remember When Managing Infusion and Injection Therapy Services 

While managing infusion billing and coding operation, billers and coders needs to ensure several things, such as: 

• Drug Classification & Purpose – In infusion therapy, Medicare and other payers may define chemotherapy broadly to include non-radionuclide antineoplastic drugs, monoclonal antibodies, and biologic response modifiers, even if used for non-cancer diagnoses (e.g., rheumatoid arthritis). Also, it is important that when billing, the therapeutic intent must get reflected as this impacts the CPT code chosen, and possibly the reimbursement rate. For example, Rituximab (used for RA or lymphoma) may be billed under chemo administration codes even when not used for cancer.  

• Hierarchy of CPT Codes – When you are dealing with pre-infusion billing, you need to know about certain coding particulars, such as:  

• 96413 – Used for chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. 

• 96365 – For initial IV infusion, non-chemo. Additionally, if chemo or biologic drugs are involved (even for non-cancer use), chemo codes take precedence. 

• Using a lower-tier code (e.g., 96365) instead of 96413 can affect your revenue negative.
  It will be deemed as having been used without proper intent, resulting in claim denial, underpayment and compliance risks.  

• Diagnosis Code Linkage – During the billing and coding process, it is essential to remember that the ICD-10 diagnosis must justify the use of a chemo or biologic agent (e.g., M05.79 for RA). It is seen that infusion therapy centers often lose their money if the diagnosis does not support the medical necessity of the drug or administration method, as the claim may be denied in such cases.  

• Prior Authorization / Payer-Specific Rules – In this domain, many biologics and chemo agents require prior authorization due to their cost and intent. And at times, payers also have clinical guidelines (step therapy, specialty pharmacy mandates, etc.) that need to be followed. So, a failure to comply with payer-specific policies often leads to denials or other undesirable outcomes.  

• Physician or Clinical Staff Supervision – When billing for infusion, it is essential that a certified physician and staff supervision are present.  Many infusion codes, especially chemotherapy administration, require direct physician supervision or professional clinical monitoring. Moreover, lack of appropriate supervision in documentation can lead to claim denials.  

• Time-based Billing – This type of billing is often time-sensitive (e.g., first hour vs. additional hours). Thus, accurate start and stop times must be properly and precisely documented. Even a small error in time documentation can lead to payment issues or audits.  

• Drug Wastage – Do you know Medicare requires the use of JW modifiers to bill for drug wastage (e.g., single-use vial, not all administered)? So any failure to report wastage properly can result in non-reimbursed drug cost.  

So whether you are managing infusion services in home or infusion centers, or in hospital outpatient departments, you need someone who is not only skilled but has experience in handling the complexities of infusion billing.   

SunKnowledge – The Solution for Seamless Infusion Billing and Injection Therapy Services  

Being in the healthcare industry for 15+ years, SunKnowledge is known for delivering state-of-the-art solutions to many leading infusion centers, at-home infusion service providers, hospital outpatient departments, and more. We provide all pre and post-billing services with a team of experienced billers and certified coders excelling in ensuring seamless infusion billing practice.   

Ensuring 99.9% accuracy and the highest productivity metrics, we can easily outperform any RCM company in the US billing domain for infusion services. With us, you get 100% infusion prior auth submissions on the same day, reduced denials for claims, and a rapid shrinking of aging AR. But don’t take our word for it. Ask any of our clients – spread across various U.S. states – and find out for yourself why we are the trusted name in healthcare billing. If you are troubled with poor collections for infusion therapy services rendered by you, we are here to help you. At only $7 per hour, get the best infusion billing services for your practice.