Getting Under the Skin of Infusion Billing: The Essential Guide

Infusion procedures are an inherent part of modern healthcare. Every day, thousands undergo them in facilities ranging from hospitals, outpatient infusion centers, oncology clinics, to rheumatology & gastroenterology practices, specialty drug clinics, and so on. In spite of its ubiquitous nature, billing for infusion services is a tough nut to crack, especially for those who are not thoroughly familiar with the many intricacies of infusion billing. Let’s delve deeper.

Getting Up & Close with Infusion Billing

Infusion billing services require all of the accuracy, attention to detail, and compliance to payer rules as billing for any other specialty. And then some more. To ensure that the patient’s health plan fully covers the cost, every claim needs to furnish some extra information than the basic facts. These include mentioning the drug used, the dosage (in units), the ‘start’ and ‘stop’ time, and a breakup of the time for which the medication was administered (the first hour + extra time).

In the absence of any of the above, or if there is an error, or a discrepancy with the accompanying documentation, the claim can be denied by the payer. Here’s a simple example to help put matters in perspective.

Imagine a patient receiving Remicade via IV (Intravenous). The infusion procedure lasts 1 hour 35 minutes. The billing must therefore use the following codes:

•    96365 – Initial infusion (first hour)
•    96366 – Additional hour
•    J1745 – Drug units (based on dosage)

If any of the details above is missing, the claim stands a high chance of getting denied.

Decoding the Codes of Infusion Billing

Infusion billing uses a range of codes that inform the payer about all the details required for reimbursement. These codes are either CPT, or HCPCS, or a combination of both.

These again pertain to various aspects of an infusion procedure. For example, certain CPT codes are used to describe how the drug was given and for how long, like 96413 which implies Chemotherapy IV infusion for the first hour, 96365 for a non-chemotherapy IV infusion for the first hour, 96415 used for chemotherapy for every additional hour, or 96366 for non-chemo infusion, used for each additional hour.

Billing for infusion procedures also requires distinguishing between a drip and a push. Some typical codes used for an IV push include 96409 (Chemotherapy IV push) and 96374 (Non-chemo IV push). Moreover, additional sequential infusions have their own set of codes, such as 96417 (used for chemo infusion, for each additional sequential drug), or 96367 (used for non-chemo infusion for every additional sequential drug).

Besides CPT codes, which are associated with the process of administering the medication, there are HCPCS “J-Codes” that describe the medication itself and are billed by unit. Some common examples include J1745 used for Infliximab (Remicade), J0129 used for Abatacept (Orencia), J9312 (Rituximab), and J1439 used for iron infusion (Injectafer).

Finding Success with Infusion Billing

It is evident from the above that billing for infusion services is no walk in the park. The slightest slip can quickly lead to the payer refusing to pay. Many infusion centers often find themselves in the grip of this problem. Having to manage affairs with an inadequate staff, and not keeping themselves updated about changes in payer rules, these facilities frequently find themselves struggling with infusion billing services.

Infusion services needs to be billed with a lot of precision and care. The documentation needs to be immaculate, the codes accurate, and no slip ups on the requisite details. In other words, it needs a good deal of dedicated attention.

This is the biggest reason why many infusion centers often opt for third-party billing service providers. By outsourcing infusion billing, facilities can instantly take a large chunk of administrative burden off their shoulders and improve outcomes. Whether it is billing for Medicare or a private insurance plan, professional billers and coders bring a kind of precision and efficiency that is often difficult to achieve with a regular in-facility set-up.

The Final Picture

Infusion billing, it is clear to see, is not a very straightforward process. It has to take into account three critical aspects viz. the actual medicine used (for example, chemotherapy drugs or biologics), the procedure (i.e. how the drug was administered, like IV push, drip, injection, etc.), and the time for which it was done. Each of these aspects needs to be accompanied by the right code, and nothing should fall through the cracks.

When done correctly, payers reimburse all applicable charges promptly. And if achieving the required level of precision is difficult, infusion practices should look beyond their regular billing personnel and workflows, and engage dedicated professionals from an infusion billing company to ensure the best results.