What is Outpatient Infusion Coding?
Outpatient infusion coding reimbursement is how you bill for infusions conducted in an outpatient setting. Outpatient infusion therapies have to be calculated and billed quite differently than inpatient infusion coding.
Why is Outpatient Infusion Coding Complex and Different than Inpatient?
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 it even includes emergency departments and observation clinics. Patients are typically ambulatory and are attending an “appointment” in a medical outpatient center. 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 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. 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; but 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.
Medical billers and coders, typically with formal training and years of experience, become frustrated having to correct mistakes made by those medical professionals with no coding experience. Workflows have been created whereby a clinical staff member—typically a doctor or nurse—does their best to interpret the billing rules as they know them and selects billing codes for the service they provided. But something to remember is that this is not their main job, so due to their lack of expertise, they are often wrong about those codes, resulting in billing errors that must be corrected by billing coders and specialists. Often, there is some kind of feedback sent back to the clinical staff that highlights their errors, with the aim of improving their coding. Errors are documented and reviewed at some later date.
The end result is predictable: coders and billers are frustrated by constantly correcting the same errors, while the clinical staff is frustrated trying to perform a function that really does require expertise that they do not possess. The process is inefficient with work being done and redone by multiple sources.
How do you bill for outpatient infusion services?
Hospital departments that do high volumes of outpatient infusions, such as Emergency Departments and Oncology for example, need an infusion charging solution because infusion billing codes are determined by the duration of infusion. For every infusion, you have to document the start and stop times. Only then can you properly complete your infusion billing.
A short infusion is any infusion under 16 minutes while a prolonged infusion is 16 minutes or more and the payment rate is different for each type. So, if an infusion lasts from 8:00 to 8:15, there’s one set of rules. If it lasts from 8:00 to 8:16, it’s a different set of rules and you get paid more, so the difference of one minute can have a significant impact on revenue. When a department is doing hundreds of infusions daily, inaccuracies for even a small percentage of infusions adds up and can have a significant impact on hospital revenue.
What is the Hierarchy for Infusion Coding?
Infusion hierarchy refers to how infusion services can be properly coded and billed to maximize the amount of revenue you get. Infusion coding must be done according to a specific hierarchy—chemo drugs before therapeutic drugs before hydration drugs—and the number of units of each is directly determined by the duration of the infusion itself. Unlike most medical procedures and services, infusion coding is actually more like a mathematical equation, one that lends itself directly to being automated.
Infusion coding can be automated – in fact, coding automation can not only save time and resources, it can also help you ensure you don’t miss charges or under code for infusion services. When it comes to most coding automation software today, nearly all of them rely on a user to enter basic information directly into the software like drug codes and start and stop times. The software then uses that information to calculate the correct billing codes and will either send that charge information to your billing system or produce a spreadsheet whose data needs to be transferred by another resource into the billing system.
While useful and typically more accurate than relying on coder knowledge alone to create billable codes, the process is nonetheless duplicative. That same information has already been documented once in the patient’s EHR record and then must be entered again to create billing codes. This double effort dramatically reduces efficiency.
Fully automated infusion coding, or autonomous coding, on the other hand, pulls that same information out of the EHR, sends the data through the infusion “calculator,”, and produces billable codes without any need to manually input data. The information has already been recorded once, so use it. This is what Charge Infusion, our coding automation software, does.