Written by Norene Anderson
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Infusions offer a challenge for reimbursement by insurance providers. Regardless of the carrier, whether Medicare, Medicaid, commercial, or managed care, the process of reimbursement follows the same pattern. The amount of reimbursement may be determined by the status of the doctor in relation to the insurance. If the plan requires the use of "in network" physicians, the reimbursement will differ if an "out of plan" physician is used.

Another factor in reimbursement for infusions is the location of administration. Some policies will cover the infusion being given in the doctor's office or as an outpatient, but will not cover the infusion if it is given in the home. It is important to make sure precertification is not required before receiving the service. It is a good idea to verify with the physician or the person responsible for insurance billing that all requirements are met.

Billing for Infusions

If precertification is required for any infusions, it is important to have all the facts readily available. The ICD-9 diagnosis code should accurately define the need for the medication. The NDC (National Drug Code) should accurately describe the type, amount, and vial size of the injectable. The appropriate HCPCS code should reflect the infusion use in conjunction with any other information necessary for approval.

Some reimbursements are made to the physician only if the expense of the drug is included in the physician's professional service. Physicians administering infusions in the office may be able to bill for an infusion service. It is important to check with the insurance provider to determine the appropriate way to handle all billing issues.

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