In the realm of rheumatology, office-administered infusions and injections play a critical role in managing a variety of conditions such as rheumatoid arthritis, lupus, and other autoimmune diseases. These treatments are complex, requiring careful administration and monitoring. However, one subject that continues to challenge rheumatology practices is inappropriate downcoding of administration codes. This is the process of billing for services using non-complex codes, which do not accurately reflect the level of service provided. If services are downcoded, practices may not receive adequate reimbursement for the time, expertise, and resources involved, ultimately leading to a negative impact on their bottom line.
Here are some of the main issues contributing to rheumatology administration downcoding and proactive recommendations to avoid improper reimbursement:
Issue: Complexity of Coding
Rheumatology infusions and injections often involve multiple steps, such as drug preparation, patient monitoring, and post-infusion care. Administering drugs of this complexity requires doctors and nurses to be trained not only on proper techniques, but also on how to recognize and treat reactions and side effects. This level of medical necessity is what warrants the high-level codes, though payers may not always process claims in such a way.
Recommendation #1: Stay Updated on Coding:
It is important to know which codes apply to each biologic administered in your office. A helpful tips and tricks coding article published by the AAPC can be found here. Additional guidelines and support can be found across many NORM resources. Webinars are available for billers to stay up to date on changes, while the payer committee offers support for commonly faced issues.
Recommendation #2: Utilize Certified Coders
Having certified medical coders with expertise in rheumatology and infusion/injection billing can significantly reduce the risk of downcoding. Coders who are familiar with the specifics of infusion therapy can help ensure accurate code selection. CRHC (Certified Rheumatology Coder) certification classes are available through the AAPC. Additionally, a virtual option supported by NORM can be accessed here.
Issue: Inadequate Documentation
Infusion and injection administration requires thorough documentation to justify the level of service provided. Missing or insufficient documentation can lead to downcoding, as the biller may not have enough information to support a higher-level code.
Recommendation: Ensure Accurate and Detailed Documentation
For infusions and injections, comprehensive documentation must include the exact drug administered, dosage, administration time, patient monitoring, and any complications that arise. CMS offers a MLN factsheet here, which details the documentation requirements to ensure compliance with complex coding.
Issue: Unclear Billing Guidelines
Insurance companies may deny complex administration codes for certain biologics or for members with particular plans. It is important to appeal and fight for the proper reimbursement across the board. A template appeal letter can be found here. It may seem easier to downcode out of caution to avoid claim rejections, but that decision will cause a negative financial impact on the practice and weaken the fight of rheumatology practices as a whole.
Recommendation #1: Review Payer Policies
Since reimbursement rates and guidelines can vary by payer, rheumatology practices should familiarize themselves with the specific billing rules for each insurance company. If the payer denies administration codes claiming to follow Medicare guidelines, reference this document, which specifically states rheumatology practices’ rights to bill complex codes according to the classification of drugs being given. The NORM community forum is also a great place to ask fellow members for advice based on their experiences.
Recommendation #2: Conduct Regular Internal Audits
Periodically reviewing claims and reimbursement reports can help identify patterns of downcoding. These audits allow practices to address any discrepancies and take corrective action before the situation worsens.
Issue: Resource Constraints
Smaller practices may lack dedicated billing staff, leading to errors in selecting the right codes. Physicians or office staff may be juggling multiple responsibilities, increasing the likelihood of mistakes.
Recommendation #1: Leverage Billing Software
Many electronic health record (EHR) systems and billing platforms offer built-in tools to guide coding and flag potential errors. These systems can help identify the appropriate codes based on the services documented and ensure that higher-level codes are used when applicable.
Recommendation #2: Join NORM
By becoming a NORM member, managers immediately gain access to billing and coding resources along with many other educational opportunities to take the stress and guesswork out of running their practice. Furthermore, NORM membership allows managers the opportunity to attend the annual conference with sessions that focus on hot topics and offer insight on industry-wide issues. For more information on the event, click here.
Coding for complex biologic infusions and injections requires attention to detail and a thorough understanding of the relevant codes and guidelines. By following the steps outlined in this blog, practices can ensure accurate billing and reimbursement for these vital therapies. As the landscape of biologic treatments continues to evolve, staying informed about coding updates and best practices will be essential for successful administration and billing.
For further resources, consider consulting the AMA’s CPT coding manual or attending coding workshops focused on biologics and infusion therapies.
Tags: medical offices, national organization of rheumatology managers, NORM, office management, office managers, rheumatologists, rheumatology, tips for office managers Posted by
