Outpatient infusion billing services are notoriously complicated – and not something that can be precisely done by manual means. So, what's the difference between inpatient vs. outpatient infusion billing? And why is one more complex than the other?
The Difference Between Inpatient and Outpatient Infusion Coding
The difference between inpatient and outpatient infusion coding is where the infusion services were delivered. This impacts what you can bill for, how you bill, and how much you can bill.
Outpatient infusion coding reimbursement refers to the reimbursement for infusion services delivered in an outpatient setting, such as a clinic, infusion center, cancer center, and even includes emergency departments and observation clinics. Outpatient reimbursement is based on a fee-for-service model, where you're paid for each specific service – aka the infusion therapy that you deliver.
The reimbursement for outpatient infusion coding is determined primarily based on the CPT code used which note the duration of the drugs that are infused, while also considering factors such as the type of medication and the dosage of that medication.
On the other hand, inpatient infusion reimbursement refers to infusion services delivered in a hospital or other inpatient facility, for patients who have been admitted to the hospital less than 24 hr. Inpatient reimbursement is usually based on a diagnosis-related group (DRG) system, where a predetermined payment is assigned to a specific diagnosis or condition. In this case, you don't get reimbursed separately for each infusion service delivered during the inpatient stay; rather, the infusion and the other services delivered are bundled into the overall payment for the inpatient stay, based on the total DRG amount you are eligible to bill for.
Outpatient reimbursement focuses on specific services provided, while inpatient reimbursement is based on the overall care received during the inpatient stay.
One of the biggest factors that plays a significant role in outpatient infusion coding and billing is the start and stop times of delivering the infusion service.
Outpatient Infusion Coding
In outpatient settings, the coding for infusion therapy is generally based on how long the therapy lasts. This is called time-based coding. To determine how long the patient has received the treatment, it is vital to note the start and stop times. In case the duration of the therapy cannot be accurately calculated due to missing start or stop times, then the apt infusion billing service code cannot be applied.
The start and stop times are used to determine the number of billable units for each drug administered by infusion therapy. Each unit generally corresponds to a specific time period. Suppose for 15 minutes, and the reimbursement is completely based on the number of these units. Longer infusion periods result in a higher number of billable units, which in turn leads to a better amount of reimbursement.
Accurate recording of start and stop times is essential to ensure correct billing and reimbursement for the actual duration of the infusion therapy.
When start and stop times are recorded manually, there is a higher chance of errors, which can lead to revenue loss.
For example, if no stop time is documented, the infusion may need to be billed automatically, which could lead to inaccuracies or missed charges.
Inpatient Infusion Coding
In the case of an inpatient scenario, infusion therapy services are grouped into a DRG payment system. The reimbursement of inpatient care depends on the patient's overall stay, which includes all the services and treatments that have been received. Organizations are reimbursed with a substantial amount of payment regardless of any individual services provided.
Inpatient infusion coding primarily centers around capturing patients' diagnoses, conditions, and details of the treatment. It does not solely depend on the start and stop time of the infusion therapy.
As the reimbursement for inpatient care does not depend on the time units, the start and stop times of the therapy are not really important for coding infusion billing solutions in the case of inpatient infusion therapy.
Although you want to precisely record every aspect of the services that are being delivered, it is crucial to be extra meticulous during outpatient infusion billing and coding.
In the scenario of outpatient infusion therapy, the start and stop times are an invaluable part of the process. This is mandatory to get proper reimbursements for the therapies that are being provided. In case you are not recording the stop times, or if the nurse has to jot down the details manually, or if it doesn't exactly match the data present in the EHR, it could cause a huge financial blunder. This might lead to the loss of thousands and even millions in the infusion billing center. So, the expert billers should be very careful when billing infusion therapy, especially in the case of outpatient billing services. With a dedicated outpatient billing process, the infusion centers can thrive in this industry.