Curbside Infusion CEO Sonia Alizzi discusses the different terms commonly used within infusion billing, compares the key differences between management and software companies, and shares her personal experience as a management provider within the industry.
Infusion administration can be a complicated case to crack, especially when it comes down to coding and billing. As a business owner of an ambulatory infusion center and infusion management company, I have committed my time and resources in assisting and recognizing the key factors in the infusion revenue cycle process, such as: medical codes, modifiers, and more. Curbside Infusion Venture LLC and 360 Medical Billing Specialists LLC gives my team and me direct insight into the infusion billing landscape and acute awareness of the need for an experienced, dedicated, and professional billing team.
Crucial Aspects of Your Infusion Operation’s Financial Wellbeing
The billing team completes the authorization process, patient assistant program enrollment, patient financial review, claim submission, and full revenue cycle management–all crucial aspects of your infusion operation’s financial wellbeing.
The authorization process is the approval or permission granted by a payer for a specific medical service or procedure. Healthcare providers obtain prior authorization or pre-certification from the insurance company before providing certain services or procedures. This involves submitting relevant documentation, such as medical records and treatment plans, to demonstrate the medical necessity of the proposed services. Authorization is crucial for ensuring that services are covered by the patient’s insurance plan, and failure to obtain it may result in claim denials.
Patient assistance programs are initiatives or services provided by pharmaceutical companies or nonprofit organizations to help patients afford the cost of medications. We assist by enrolling eligible patients in patient assistance programs to access copay assistance or discounted/free medications. This may involve completing applications, providing financial information, and meeting specific eligibility criteria set by the assistance program. Enrollment in these programs can significantly reduce the financial burden on patients and improve their access to necessary medications.
Patient financial review involves assessing a patient’s ability to pay for healthcare services and determining potential financial assistance options. Healthcare billing teams evaluate patients’ financial situations by considering factors such as income, insurance coverage, and outstanding medical bills. Billing teams often serve as financial counselors who work with patients to explore payment plans, discounts, or charity care options based on financial need. This process aims to ensure that patients receive necessary care while addressing financial concerns and constraints.
Claim submission is the process of sending a request for reimbursement to the payer for healthcare services provided.
After providing services, healthcare providers compile relevant information, including patient demographics, diagnoses, procedures, and insurance details. Claims are submitted electronically or via paper, depending on the
provider’s system and payer requirements. Accuracy in coding and documentation is critical to avoid claim denials and facilitate timely reimbursement.
The revenue cycle management involves managing the financial aspects of a healthcare organization, from patient registration to final payment as follows:
- Intake & Benefits Investigation: payer eligibility verification; prior authorization/pre-certification; financial review and patient assistance enrollment
- Charge Capture: accurate recording of services provided and assigning appropriate codes
- Claims Process: submission of claims to payers, followed by processing and adjudication
- Payment Posting: recording payments received from payers and patients
- Denial Management: addressing and resolving claim denials to ensure maximum reimbursement
- Accounts Receivable Follow-Up: monitoring and pursuing outstanding payments from payers and patients
- Financial Reporting: analyzing financial data to assess the organization’s performance and identify areas for improvement
Stay Updated on All Medical Billing and Miscellaneous Codes
Billers are required to stay up-to-date on all medical billing codes, as well as the new Food and Drug Administration (FDA)-approved medications with miscellaneous codes. Improper codes and/or billing units could have a financial impact on your reimbursement.
A HCPCS code refers to a Healthcare Common Procedure Coding System Level II alpha-numeric code issued by the Centers for Medicare & Medicaid Services (CMS) to identify and describe a drug product. Billing accounts for the appropriate medication code, the total dosage using units, and the method of administration using a JA modifier for intravenous (IV) method of administration and a JB modifier for subcutaneous (Sub-Q). Then we have JW and JZ modifiers to account for wastage. Knowing how many units to bill for is also of great importance, especially when billing Medicare (e.g. one billing unit for a drug could be equal to 10mg of the drug in a single use vial). Billing accurate units is not only a compliance issue but has financial ramifications. Pharmaceutical manufacturer websites (e.g. Genentech, Horizon, GSK, Biogen, and Novartis) are a wealth of knowledge when looking for accurate codes and billing units to utilize.
Specifically, J codes are used to identify and report drugs that are administered in a physician’s office, clinic, or other healthcare setting. They help in the billing and reimbursement process by providing a standardized way to document and report administered medications. The J codes are typically composed of five characters, starting with the letter “J” followed by four numeric digits (e.g. J1234). Sometimes, a two-letter suffix is added after the numeric part to provide additional details about the drug or its administration (e.g. J1234-AA).
Drug Examples:
- J0129 – Abatacept (Orencia) per 10mg: Abatacept is used to treat rheumatoid arthritis.
- J1745 – Infliximab (Remicade) per 10mg: Infliximab is commonly used to treat autoimmune diseases like rheumatoid arthritis and Crohn’s disease.
These codes are used on healthcare claims to specify the drug and its dosage when it is administered by a healthcare provider.
Modifiers are codes used to provide additional information to payers about certain circumstances that may affect the reimbursement of a service, procedure or administered medication. Modifiers help ensure accurate and specific documentation of the services provided. Each modifier conveys a different meaning. Below are explanations and examples of certain modifiers commonly used in infusion billing: JA, JB, JW, and JZ.
JA Modifier: Used to identify drug or biological products that are administered intravenously.
- Example: Suppose a patient receives a drug intravenously, and the specific code for that drug is J1234. If the drug is administered intravenously, you would append the JA modifier to the J1234 code (J1234-JA).
JB Modifier: Applied to identify separately payable drug or biological products that are acquired through the 340B Drug Pricing Program.
- Example: If a hospital obtains a drug through the 340B program and administers it to a patient, the JB modifier would be added to the appropriate drug code to indicate that it was acquired through the 340B program (e.g. J5678-JB).
JW Modifier: Used when a drug or biological product is discarded and not administered to the patient.
- Example: If a healthcare provider administers a drug but discards a portion of it (e.g. due to a
vial being partially used), the JW modifier is added to the drug code to indicate the amount of discarded drug (e.g. J6789-JW).
JZ Modifier: Applied when documenting the amount of drug or biological product actually administered to a patient.
- Example: If a provider administers a partial dose of a drug, the JZ modifier is used to specify the amount of the drug actually administered (e.g. J3456-JZ15 for 15mg of the drug).
Additional considerations:
- Modifiers are generally two alphanumeric characters appended to the Current Procedural Terminology (CPT®) or HCPCS code.
- Modifiers are not used to alter the description of a procedure; instead, they provide additional information about the circumstances of the service.
- Always follow specific payer guidelines and coding conventions when using modifiers.
Remember, the appropriate use of modifiers is essential for accurate billing and reimbursement. Misuse or improper application of modifiers can lead to claim denials or payment discrepancies. Healthcare providers should stay updated on coding guidelines and payer policies to ensure compliance.
CPT Codes
According to the American Medical Association (AMA), CPT® codes “offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency.” Infusion providers use CPT codes such as 96413, 96365, and 96372 to bill for the services related to the infusion and/or injection of medications.
Medical coding is crucial for accurate billing and reimbursement, ensuring that healthcare providers are appropriately compensated for the services they provide and the drugs they administer. CMS and the AMA, as applicable, regularly update CPT and HCPCS codes to reflect changes in medical practice, technology, and the introduction of new drugs.
Infusion Management Services vs. Software Companies
Do you ever ask yourself what the difference is between an infusion management company and a software solution? Well, you are not alone. Perhaps this will be of assistance to you.
Infusion management companies typically offer turnkey services to physician practices and healthcare organizations. These services generally include intake and prior authorization management; patient scheduling; clinical staffing and training (e.g. infusion nurses); medication procurement; and billing and revenue cycle management. Most infusion management companies (also known as managed service organizations or MSOs) desire to fully-manage the infusion operation, allowing their physician practice and healthcare organization clients more time to focus on their patients and the practice itself. Before choosing an MSO, it’s important to interview several to find the right one. Each MSO has different fees, underlying ownership, and may or may not be affiliated with a pharmacy.
With software solution companies, it is as it sounds. These companies provide software that allows infusion providers to manage operations through a feature-driven platform. However, not all software solution companies are created equal. As an infusion provider, it is important to have a comprehensive software solution to support the specific workflow. Find a software solution that solves pain points specific to the infusion workflow. I believe it’s important that the software solution has infusion industry domain expertise, a proven tenure as a software solution, and is constantly evolving its platform and expanding its features. Customer service and ease of use are also key factors to consider before deciding.
During my time in the infusion industry, I have noticed that many people get hung up solely on the expense of the software. Instead, consider this: a software solution is mission critical to your infusion operation–if the software offered is the right solution, then it will be worth every dollar and oftentimes pays for itself.
My Personal Experience with a Software Solution Company
Curbside Infusion Venture LLC and 360 Medical Billing Specialists LLC pride ourselves on staying up-to-date on the latest information pertaining to infusion and injectable administration and billing. We are known in the industry for our knowledge, professionalism, and transparency when working with our customers. We also proudly utilize WeInfuse as our software of choice. We utilize the WeInfuse software to manage all our clients’ infusion workflows, which gives us the ability to efficiently track all aspects of the patient referral process under one system.
Having a purpose-built infusion-specific software solution provides our team and clients peace of mind as the status of every infusion patient is tracked throughout the entire journey. With WeInfuse, our team has the ability to manage our medications and keep a perpetual inventory to assure we always have the medications on-hand for each appointment. Our clients are also given access to WeInfuse so they can follow each patient and hold us accountable.
Most recently, our company has started utilizing the billing & claims feature set of WeInfuse, and it has already made a tremendous difference for us and our clients. The reporting gives us the ability to provide detailed reports that our previous billing system could not supply. Lastly, the WeInfuse software allows our company the ability to scale and expand our services beyond Texas.
What to Take Away From All of This
In summary, a strong billing and operational team is vital for success in the infusion space. Choose the right MSO or invest time in building a strong revenue cycle strong team that is committed to staying informed and abreast of the ever-evolving infusion billing, compliance, and regulatory landscape.
Additional Resources
Want to dive deeper? Check out the WeInfuse Infusion Playbook (here)! This eBook covers three main topics: infusion billing, inventory management, and how to be victorious in the infusion space.
Guest Author: Sonia Alizzi has over twenty-five years of extensive experience in infusion administration. As an infusion registered nurse, Sonia possesses the clinical and operational know-how to manage all aspects of infusion therapy. She manages clinical teams, processes, and protocols to warrant the standard of care exceeding patient and physician expectations. Sonia plays a critical role in the development and growth in the infusion management services line of business and continues to be a recognized key player in her field of expertise. She is committed to applying her experience and expertise in growing her infusion management and billing company.
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