The Challenge

The Buy-and-Bill Revenue Challenge

Oncology practices carry millions of dollars in drug inventory that must be billed, tracked, and reimbursed accurately. Between ASP fluctuations, NDC-to-J-code crosswalk errors, wastage documentation, and sequestration adjustments, the margin between profit and loss on every infusion chair is razor-thin.

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Chemotherapy Administration Coding

Chemo administration codes (96401-96417) require precise documentation of technique (IV push, infusion, subcutaneous), timing, sequence (initial vs. subsequent substances), and concurrent vs. sequential administration. We ensure every chair minute is captured with the correct hierarchy of administration codes.

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Infusion Billing Optimization

Non-chemotherapy infusions (96365-96368) for supportive care, hydration (96360-96361), and therapeutic injections follow a complex hierarchy. The first infusion hour, additional hours, sequential infusions, and concurrent infusions each have distinct coding rules. We maximize compliant capture of every infusion service delivered.

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Buy-and-Bill Drug Management

We manage the entire buy-and-bill revenue cycle — mapping NDC numbers to correct J-codes, tracking ASP quarterly updates, documenting drug wastage (JW modifier), managing biosimilar substitutions, and reconciling drug purchase costs against reimbursement to identify underwater drugs before they erode your margins.

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Radiation Therapy Coding

Radiation therapy billing spans treatment planning (77261-77263), simulation (77280-77295), IMRT delivery (77385-77387), SBRT, proton therapy, and brachytherapy. Each modality has distinct professional and technical components. We ensure accurate coding across the full radiation treatment course from planning through delivery.

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Immunotherapy & Targeted Therapy

The rapid expansion of immunotherapy agents (pembrolizumab, nivolumab, ipilimumab) and targeted therapies has created new billing complexities around drug coding, weight-based dosing calculations, combination therapy sequencing, and irAE management coding. We stay current with every new agent approval and its billing implications.

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Clinical Trial Billing Compliance

Separating routine care costs (billable to insurance) from investigational costs (covered by the trial sponsor) is a critical compliance requirement. We implement clinical trial billing workflows that correctly identify coverage analysis determinations and prevent both underbilling of routine services and erroneous billing of research services to insurance.

Our Approach

End-to-End Oncology Revenue Cycle Management

Our oncology billing team includes certified coders with deep expertise in medical oncology, radiation oncology, and hematology. We understand that oncology revenue is driven by drug reimbursement and infusion chair optimization — and we treat every dollar of drug cost as a recoverable asset.

ASP+6% reimbursement tracking with quarterly drug pricing analysis to identify underpayments and underwater drugs requiring contract renegotiation or formulary adjustment
Oral oncolytic parity billing ensuring compliance with state parity laws that require equivalent coverage for oral cancer drugs vs. IV-administered equivalents
Molecular and genomic testing billing for next-generation sequencing (81445, 81450, 81455), companion diagnostics, and liquid biopsy with proper medical necessity documentation
Port procedures including placement (36560-36566), access (36591-36592), and removal with proper global period tracking
Supportive care coding for antiemetics, growth factors, blood transfusions, and pain management integrated into the oncology treatment plan
Cross-specialty coordination with pain management, nephrology, and gastroenterology for comprehensive cancer care billing

Our Process

How We Optimize Your Oncology Revenue

Pre-Treatment Authorization

We obtain prior authorizations for chemotherapy regimens, immunotherapy, radiation courses, and high-cost supportive medications. Our team verifies benefits, calculates patient cost-sharing, and identifies financial assistance programs before treatment begins.

Treatment Day Charge Capture

On treatment days, we capture every billable element — drug codes with correct units, administration codes in proper hierarchy, E/M services with modifier -25, hydration, and supportive medications. Drug wastage is documented with JW modifiers for compliance and reimbursement.

Drug Cost Reconciliation

We reconcile drug purchases against reimbursements monthly, tracking ASP-based payments, contract rates, and 340B pricing where applicable. This analysis identifies underwater drugs, reimbursement trends, and opportunities to optimize your formulary for financial sustainability.

Denial Recovery & Revenue Assurance

Oncology denials often involve high-dollar claims. We have dedicated appeals specialists who handle drug authorization denials, medical necessity challenges, and underpayment disputes with clinical evidence and peer-to-peer coordination to recover maximum reimbursement.

FAQ

Oncology Billing Questions Answered

Chemotherapy administration follows a strict hierarchy. The first drug infused uses the initial infusion code (96413 for the first hour). Additional hours of the same drug use 96415. A second chemotherapy drug administered sequentially uses 96417. If drugs are administered concurrently, additional concurrent infusion codes apply. IV push chemo uses 96409 (initial) and 96411 (additional substances). We ensure the coding hierarchy maximizes reimbursement by sequencing the highest-paying administration code first and correctly applying add-on codes for each subsequent drug and method.

We manage the complete buy-and-bill cycle: mapping each drug's NDC to the correct J-code with accurate unit calculations, tracking quarterly ASP updates from CMS to identify reimbursement changes, documenting wastage with JW modifiers, managing biosimilar substitutions, and reconciling purchase costs against payments. We flag any drug where reimbursement falls below acquisition cost and provide data to support contract renegotiations with payers. For 340B-eligible practices, we ensure separate tracking and billing compliance.

Immunotherapy agents like pembrolizumab (J9271), nivolumab (J9299), and ipilimumab (J9228) are billed using their specific J-codes with units based on the dose administered. Administration is coded using chemotherapy infusion codes (96413-96417) since immunotherapy is classified as antineoplastic therapy. Weight-based dosing requires accurate unit calculation, and combination immunotherapy regimens (e.g., nivolumab + ipilimumab) follow the same sequential/concurrent administration hierarchy as traditional chemotherapy. We track flat-dose vs. weight-based dosing changes as agents receive updated FDA labeling.

We implement a structured clinical trial billing workflow based on the coverage analysis for each trial. Routine patient care costs — such as standard-of-care imaging, labs, and office visits that would occur regardless of trial participation — are billed to the patient's insurance. Investigational items — study drugs, protocol-mandated extra tests, and research-only procedures — are billed to the trial sponsor. We maintain a billing grid for each active trial and train front-end staff on proper charge routing to prevent compliance violations and ensure no revenue leakage on billable routine services.

We code the full range of molecular and genomic testing used in oncology: next-generation sequencing panels (81445 for 5-50 genes, 81450 for 51+ genes, 81455 for tumor analysis), specific gene tests (BRCA1/2, EGFR, ALK, ROS1, PD-L1), liquid biopsy (0239U and related PLA codes), and microsatellite instability testing. We ensure proper ordering provider documentation, medical necessity for the specific test ordered, and correct billing to the lab or reference laboratory based on your practice's testing model.

Radiation therapy billing spans the entire treatment course: initial consultation, treatment planning (77261-77263 based on complexity), simulation (77280-77295), dosimetry (77300-77334), IMRT delivery (77385-77386), image guidance (77387), and weekly management (77427). Each component has professional and technical splits. We ensure every planning session, treatment fraction, and management visit is captured, that treatment plan complexity supports the planning code billed, and that the correct number of fractions are reported for each course of treatment.

Over 40 states have enacted oral chemotherapy parity laws requiring insurers to cover oral cancer drugs with cost-sharing no greater than IV-administered equivalents. We track applicable parity laws by state, ensure patients receive parity protections when applicable, assist with specialty pharmacy coordination, and bill oral oncolytics through the pharmacy benefit with proper prior authorization. When parity violations occur, we work with the practice to file appeals and state insurance department complaints to enforce the patient's rights to equitable coverage.

Port-a-cath procedures include placement (36560 for central venous, 36561 for with subcutaneous port), access for infusion (36591 for implanted port, 36592 for pump), declotting (36593), and removal (36590). Port placement carries a 10-day global period. We track global periods, ensure port access is billed on each infusion day, coordinate facility and professional fee billing for surgical placement, and manage device tracking including manufacturer, model, and serial number documentation required by many payers.

Compliance & Security

HIPAA-Compliant Oncology Billing Operations

Oncology billing involves some of the most sensitive patient data in healthcare — cancer diagnoses, treatment protocols, clinical trial participation, and high-dollar drug records. Our operations adhere to HIPAA, ISO 27001, and HITRUST security frameworks with additional safeguards for oncology-specific data sensitivity.

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Protected Health Data

All oncology patient records, treatment histories, and drug administration data are processed within encrypted, access-controlled systems with full audit trails. Our team undergoes specialized training on the sensitivity of cancer diagnosis information and clinical trial data.

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Drug Billing Compliance

We maintain rigorous compliance protocols for buy-and-bill drug documentation, wastage reporting, 340B program integrity, and clinical trial billing separation. Quarterly audits verify J-code accuracy, unit calculations, and NDC crosswalk integrity across your entire drug formulary.

Oncology & Hematology Billing That Recovers Every Dollar from Complex Cancer Care