Infusion Billing Services

Infusion claims are among the most valuable a practice sends, and among the easiest to underpay. One chair can carry a drug worth thousands of dollars. Each claim has two halves: the administration, coded from the minutes in the note, and the drug, billed in units, often with an NDC and a waste modifier. Get either half wrong and the payer pays the part it can match and denies the rest.

Our infusion billing services cover ambulatory infusion centers, infusion suites inside oncology, rheumatology, gastroenterology and neurology practices, and home infusion providers. Practices come to us for infusion billing outsourcing when the drug spend has grown faster than the billing team. We handle the authorizations, the coding, the claims and the denials as one job.

Who we bill for

• Ambulatory infusion centersFreestanding centers taking site-of-care referrals from hospitals, with high-cost biologics and heavy prior authorization.
• Physician office infusion suitesOncology, rheumatology, GI, neurology and allergy practices administering drugs they buy and bill.
• Home infusion providersPharmacies and nursing agencies billing per diems, drugs and nursing visits for patients treated at home.
• Multi-specialty groupsPractices where infusion is one service line among several and nobody owns its rules.

Administration codes: time decides the code

Drug administration is coded from the documented start and stop times. An infusion note without times cannot support the add-on hours, and an infusion that ran 15 minutes or less is reported as a push, not an infusion.

Only one initial service is reported per encounter. In the office, the initial code follows the main reason for the visit. Facilities follow a hierarchy instead: chemotherapy first, then therapeutic infusion, then push, then hydration. An additional hour needs more than 30 minutes beyond the first. Mixing those rules up is one of the most common reasons an infusion claim underpays.

The drug side: units, NDCs and waste

• HCPCS units Most drugs are billed with a J-code whose description sets the unit, for example per 10 mg. Billing milligrams instead of units is a costly error that is easy to miss.
• NDC on the claim Medicaid requires the 11-digit NDC, a unit qualifier and a quantity on physician-administered drugs. Many commercial payers do too. The NDC must match the vial actually used.
• JW and JZ modifiers On single-dose containers, Medicare Part B expects the discarded amount on a separate line with JW, or JZ to confirm nothing was discarded. Both must be supported by the record.
• Biosimilars and new drugs Biosimilars have their own codes. A newly approved drug may bill under a miscellaneous code with an invoice until it gets one.
• Drug cost against payment Medicare pays most Part B drugs from the average sales price. We compare what each payer pays for your top drugs with what you paid for them, so an underwater drug is visible before you keep buying it.

Prior authorization and site of care

Most commercial and Medicare Advantage plans require prior authorization for infused biologics. Many approve a set number of doses for a fixed period, and some name the site of care. An authorization for the wrong site, the wrong number of doses or an expired date is a full denial on a very large claim.

We track each authorization against the doses scheduled, re-authorize before the last approved dose, and confirm that the drug, the code and the site on the claim match the approval. Where a plan requires white bagging through a specialty pharmacy, we bill only the administration. See our prior authorization services.

Home infusion billing

Home infusion is billed differently from infusion in a chair, and the rules depend on the payer:

• Commercial plans usually pay a per diem for pharmacy services, supplies and equipment, billed with HCPCS S-codes, plus the drug and nursing visits (99601 and 99602) separately.
• Medicare Part B covers certain drugs given through an external infusion pump under the DME benefit. Qualified home infusion therapy suppliers also bill the professional service visits (G0068 to G0070).
• Medicare Part D covers many other home infusion drugs, but not the services and supplies around them. That gap needs explaining to patients before the first dose.

Outsourcing home infusion billing and collections works best when intake, benefits checks and billing sit with one team. Most home infusion denials start at intake, not at the claim.

How we run infusion billing

1. Benefits and authorization checked for every new referral and every new drug, before the first dose.
2. Charge capture from the infusion record: drug, dose, NDC, waste and start and stop times.
3. Coding of administration and drug lines, with the initial service and add-on hours checked against the times.
4. Claim scrubbing for units, NDC format, JW and JZ, and authorization match before submission.
5. Payment posting line by line, with underpaid drug lines flagged against the payer's contract.
6. Denials and appeals worked weekly, with the clinical record attached where medical necessity is the issue.
7. Monthly reporting on collections, denials by reason, and drug payment against acquisition cost.

Why infusion claims deny

What infusion billing costs

Like the rest of our billing, infusion billing is priced as a percentage of what we collect, so we only do well when you do. The rate depends on your volume, payer mix and how much authorization work your drugs need. Because drug payments are large, ask any company you compare whether its percentage applies to the drug lines as well as the administration. You get our number in writing before anything starts.

Infusion centers usually need payer enrollment first. A new site has its own contracts. See our medical credentialing services, and for oncology practices our oncology billing services.