Infusion Billing 101: A Beginner’s Guide to Accurate infusion Therapy billing and Coding Reimbursement
Infusion billing services are getting in your way of submitting clean claims to the payers, you are at the right place. With our rich experience in providing complete support in pre- and post-billing for infusion services, Sunknowledge is your definitive destination for full assistance in A-Z of infusion billing.
Infusion services are not easy to handle. It requires adequate knowledge, constant awareness of changing codes and infusion billing experience. As when it comes to coding and billing for your infusions and injections, providers must follow the proper CPT guidelines, payer’s requirements various billing guidelines to ensure a seamless billing operation. The infusion and injection billing services are determined based on two factors- whether the services are reported by a physician or a facility. In most cases, physicians and facilities may report only one service code unless the patient’s condition or protocol requires two intravenous (IV) sites. The time and effort differences in providing the second IV site should be reported using the initial service code and an accurate modifier.
Why Choose Us for Infusion Billing Services?
Managing infusion billing and coding services in fact is a great deal. You not only need to look after multiple aspects like specific billing requirements, covering the right CPT codes /HCPCS description, chemotherapy administration, infusion start/stop time, hydration infusions drug administration, IV push start/stop time but also various other limitations and exclusions in the medical records. Also it is important to know that drug administration codes are services that reference time and are “time based” codes.
So for a seamless infusion billing, a proper hierarchy should be maintained to support the bill and maximum amount of revenue. For example – Chemotherapy drugs come first, followed by therapeutic drugs, and then hydration drugs—the quantity of each is directly determined by the duration of the infusion and having SunKnowledge by your side can be great help for ensuring a seamless billing transaction and better ROI for your infusion billing services.
Infusion Drugs We Commonly Support: Our billing workflows are customized for commonly infused biologics and specialty drugs such as Infliximab (Remicade), Entyvio, Stelara, Inflectra, and other high-cost medications frequently used in gastroenterology, neurology, and immunology.
Understanding injection/infusion hierarchy for facility reporting
Key challenges faced by most infusion centers in United States:
In the intricate domain of medical billing and coding, infusion coding, claims and AR stands out as a challenging area. With limited experience and knowledge in the healthcare industry, infusion professionals often face the following challenges-
- Precision problem in coding duration
- Documentation related to specific drugs
- Navigating complex coding guidelines
- Documentation complexity
Understanding Infusion Therapy and Its Forms
Being one of the most complex domain, infusion therapy is all about direct introduction of medicine into the body mainly through veins without going through the digestive system or swallowing. Do you know there are 4 broad categories in doing so? People are mostly familiar with three:
Intravenous (IV), Epidural, Subcutaneous, and Intramuscular infusions.
IV infusion – Being the most common, delivers medication straight into the blood stream through a vein. And of course the most useful for immediate action in the treatment of- dehydration, infection, chemotherapy, chronic disease know as IV therapy.
Epidural infusion– This is when the administers drugs to epidural space surrounding the spinal cord, typically for use in labor or chronic pain management. Mainly for pregnant women.
Subcutaneous infusion – This is when the injection of drug is given below the skin, commonly administered for insulin, biologics, and hormones due to their slow and steady absorption helping the patient heal.
Intramuscular infusion – Lastly here the administers drugs deep into the muscular mass, allowing for more rapid absorption compared to subcutaneous routes. It is often administered for cases like vaccines, antibiotics, or hormone replacement.
Additionally, let us not forget that any technique has a definite aim and potential side effects.
However, with all these let not forget the challenge that is associated with IV injections that at times may lead to vein irritation, infection at the site of the injection, or even allergy for few. Also, for few epidural injections at times for few people may lead to headaches, hypotension, or nerve damage, so one need to be extremely careful about it. Do you know subcutaneous injections may lead to local inflammation, redness, or tenderness? Not to forget intramuscular injections may lead to soreness, bleeding, or stiffness. So it is always advised to be careful during infusion therapy. The overall aim of all infusion types should be to provide scheduled delivery of medication, bypass the stomach, and avoid swallowing complications—making it especially helpful for patients intolerant to oral medications.
Where infusion therapy is needed:
Common autoimmune disorders: Rheumatoid arthritis, lupus, Crohn’s disease, ulcerative colitis, psoriasis, multiple sclerosis are some common disorder
How Infusion is beneficial:
- Delivers biologics (e.g., infliximab, rituximab) that suppress immune activity and help individual.
- Suppresses inflammation and prevents disease progression.
- Offers uniform drug levels, usually more beneficial than oral therapy.
Congestive Heart Failure (CHF) – This is when the heart is unable to pump sufficient blood for the body’s requirements.
How infusion assists:
- Delivers inotropic agents (e.g., milrinone, dobutamine) to increase cardiac output.
- Suitable for patients with severe CHF needing prolonged monitoring.
- Applied for both acute hospital and chronic home-care therapy.
Immune Deficiencies – Common variable immunodeficiency (CVID), severe combined immunodeficiency (SCID) etc
How infusion helps:
- It is replacing the missing antibodies through the use of IVIG or SCIG (immunoglobulin replacement therapy).
- Further helps in reducing the frequency and severity of infections.
- Extremely vital as it helps the immune system in patients with compromised or failing immune systems.
Chronic Pain Conditions – Fibromyalgia, cancer-related pain, complex regional pain syndrome (CRPS).
How infusion helps:
- Administers analgesics, ketamine, or lidocaine through controlled IV infusion.
- Relieves when oral medication is not effective or less tolerated.
- Can be titrated to patient’s pain severity and tolerance.
Infections Unresponsive to Oral Antibiotics – Osteomyelitis, endocarditis, cellulitis, pneumonia, sepsis.
How infusion is useful:
- Delivers high-dose IV antibiotics like vancomycin or ceftriaxone directly into the bloodstream.
- Leads to quick therapeutic drug levels.
- Necessary in treatment of life-threatening or drug-resistant infections.
Other potent drugs given via infusion therapy are as follow and equally important:
- Antibiotics this mainly for the resistant or severe bacterial infections suffered by the individual
- Antifungals – To treat systemic fungal infection efficiently
- Corticosteroids – Used for inflammation control in autoimmune and allergic disease.
- Insulin – For aggressive control of glucose in Type 1 diabetes patient.
- Biologics – For inflammatory and autoimmune conditions.
- Chemotherapy – For cancer therapy that requires precision dosing to cure the cancer
- Blood factors – For hemophilia and other bleeding disorder.
Other Conditions Treated by Infusion
- Osteoporosis – Bisphosphonates increase bone density and reduce fracture risk.
- Hemophilia – Clotting factors prevent frequent bleeding attacks.
- Hypercoagulation disorders – Anticoagulant infusion to prevent blood clots.
- Severe migraines – “Cocktail” medications relieve severe, unresponsive headaches.
- Multiple sclerosis – Immunomodulators and corticosteroids reduce flare-ups.
- Crohn’s & Ulcerative Colitis – Biologics reduce inflammation and relapse prevention.
Measurements to take during infusion therapy:
Before beginning infusion therapy, a nurse assures all measures of safety by checking patient identity, the right medication and dose, time, and method of administration in order to safeguard patient health and maximize therapeutic efficacy.
- Adherence to regulatory updates
- Coding for different scenarios
- Problems with infusion AR management
Some interesting infusion billing and coding facts-
- When you bill IV hydration along with IV pushes, always report the IV push as the initial code.
- According to the CPT hierarchy, the initial code must be 96374.
- Following that code, 96361 must be assigned for the hydration.
- The CPT hierarchy is based on the instructional notes found in the CPT book. You need to see parenthetical notes following both 96374 and 96361
- Concurrent codes are not to be used for multiple drugs within the same bag
- Typically concurrent is used for “gravity drip” infusion methods
- 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour
- 96361 Intravenous infusion, hydration; each additional hour (list separately in addition to primary code)
However, today with all these confusion, outsource your infusion billing practices is the best alternative solution. Outsourcing to the best infusion billing expert will not only help you save time but also reduce your claims denials rate and make your coding and billing process way easy.
And as you know that infusion coding requires substantial time and effort. And outpatient infusion coding requirements are more complex than in-patient setting. It is best to have dedicated resources managing your infusion coding services.
Sunknowledge: A comprehensive infusion billing and coding support:
With more than a decade of experience in the medical billing domain, we always ensure accurate and complete infusion and injection billing & coding operation. At Sunknowlege, we are highly equipped to provide timely and accurate infusion billing, coding, claims AR and more services to receive maximum reimbursement for your practice. Our team possesses comprehensive knowledge and expertise in managing various CPT, ICD-10, and HCPCS codes associated with infusion and injection, including the latest modifiers. Our certified coders consistently stay informed about the most recent guidelines and coding domain changes to provide you with accurate and up-to-date services. With nearly 17 + years of experience, we understand the intricacies of optimizing your entire medical billing infrastructure make us the best in the infusion domain.
Why us as your Infusion Billing Support-
- Timely and precise delivery of charge sheets within client-specified turnaround time (TAT)
- Continuous monitoring, analysis of codes and timely claims management to prevent potential denials and ensure optimal reimbursements
- Ongoing training for to stay updated with the latest infusion billing & coding advancements and current practices
- Emphasis on a prompt report-back mechanism to facilitate efficient communication
- All coders hold ICD-10 certification, showcasing their expertise and proficiency
- Consistent maintenance of a 99.9 % coding accuracy rate
- Adherence to 100% HIPAA compliance, prioritizing the security and confidentiality of patient information.
As a New York based leading RCM company, we enable you to slash your operational costs by almost 80 % in no time.
Our Infusion Billing Service Portfolio:
Pre-billing Services:-
- Eligibility Verification
- Prior Authorization
- Medical Coding
- Doctor’s Office Follow-up for documents etc.
- Re-Authorization
- Order Entry (Patient, Provider, Insurance, Item etc.)
- Order Confirmation
- Scheduling of Delivery
- Virtual Assistance, and more
Post-billing Services:-
- Creation of Claims
- Claims Submission
- Claim Rejection Management
- Payment Posting – Auto & Manual
- Accounts Receivable and Denial Management
If you are looking to streamline your infusion billing and coding services expenses while enjoying improved cash flow, we are your ready-to-go partner. If you want to know more about our services, schedule a no-obligation call with us.
FAQ’s on Infusion Billing
Why Should We Look to Outsource Infusion Billing?
While a patient receives a therapeutic infusion of a drug for one hour, specialized professionals know how to report CPT code 96365 for diagnosis, prophylaxis, or therapy. Finding in house team that knows it all can be difficult. Outsourcing of infusion billing reduces your operational costs, improves your focus on patient care, and transforms your cash flow.
Why will I Outsource Infusion Billing to Sunknowledge?
We offer seamless proficiency, great experience in working on infusion billing, and have excellent references across the industry. Sunknowledge delivers complete pre and posts billing support at $7 per hour reducing your operational costs by almost 75%.
Do You Work With Startup Infusion Billing Service Providers?
Yes, we have over 100 clients all across DMEPOS and infusion billing space. Our team is versatile and has the experience of working with startup sets ups as well as leading names. We offer dedicated resources and have a niche ability to work as your operational extension.
If a patient is having an IV infusion for hydration and the stop time is not recorded in the medical record, how should the service is coded?
Infusion durations should be recorded. Hydration of 30 minutes or less is not billable separately. On request, providers are to document the volume, start and stop times, and infusion rate(s) of solution administered. Without a stop time, the provider must be able to calculate the infusion stop time using the volume, start time, and infusion rate and code it accordingly.
What is the distinction between an IV infusion and an IV push?
An IV push is an administration of 15 minutes or shorter and must have the health care provider that is injecting present to monitor the patient at all times.
To bill an IV infusion, there must be an administration of over 15 minutes for safe and effective delivery.
Do you support prior authorization for specific infusion drugs?
Yes, we do. We help with prior authorization and billing for commonly used infusion drugs like Infliximab, Entyvio, Stelara, and others. Our team ensures the process is smooth, accurate, and hassle-free for your practice.
What are The Immediate Benefits if I Outsource to You?
We can reduce down your operational costs by 75%, improve collections by 30% to 40% within the first month itself, you can get access to an experienced team of medical billers ready to work for you at next door rates with seamless standards in communication. Also, we offer you dedicated account managers and customize according to your protocols.
How Soon Can We Start Our Infusion Billing?
We can start working immediately! After signing the initial scope of work, we will allocate your work to the concerned manager and his team. We will organize the transition, to understand your process and develop the manual which will be the point of reference for us during our working together. We also have a no binding contract.
What is The Cause of Error in Infusion Billing?
Documentation fails to verify administration via a distinct access site
- Inadequate documentation for the line flush in between drugs renders it impossible to ascertain whether compatible substances or drugs were given together or in sequence
- The insufficient recording of the site of access and/or each drug’s beginning and end times prevents it from being possible to know if similar substances or medicines were combined within the same syringe or bag or given apart
- The beginning and/or end times of each substance given are frequently incomplete
- Record of infusion service was initiated on the scene by emergency medical services (EMS) and continued by the emergency department (ED)).
- Infusion services that were started in the ED were documented on admission to outpatient observation status
- Collaboration with vendors regarding electronic health records (EHR) to implement updates to electronic forms to meet evolving documentation requirements was challenging
When can a sequential infusion be charged?
After the first infusion is completed, sequential infusions can be charged for the administration of another drug or service via the same IV access. There should be a clinical rationale that supports the sequential (as opposed to concurrent) infusion. Sequential infusions can also be charged only once for each sequential infusion of same infusate mix.
How many initial services can be billed daily?
One initial code per patient encounter is permitted except for when two distinct IV sites are medically necessary and appropriate (use modifier 59 ). If the patient revisits for a distinct and medically necessary and appropriate visit/encounter on the same day, an additional initial code can be billed on that visit using CPT® modifier 59.
There is no simultaneous code for either a chemotherapeutic IV infusion or hydration. Can a simultaneous infusion be billed?
Any hydration, therapy, or chemotherapeutic infusion that is simultaneously and via the same IV access as another reportable initial or subsequent infusion constitutes a concurrent infusion. Concurrent hydration administration is not billable through a HCPCS code and not separately payable. Chemotherapeutics are not generally infused concomitantly, but if a concomitant chemotherapy infusion were to happen, the infusion would be coded with the chemotherapeutic unlisted code.
Looking to know more about our infusion billing action plan! Let us share our best practices, references across the industry, and the ability to work as your reliable operational arm over a “no commitment call”! We are just a call away!