Neurology infusion billing,
on a six-month clock.
MS infusion therapy is oncology unit math stretched over a long interval. Loading doses, maintenance measured in months, restricted distribution programs that never appear on the claim and can still invalidate it, and site-of-care policy that keeps moving underneath the schedule.
A loading dose is two claims that have to agree months later
Several MS therapies open with a split loading dose weeks apart, then settle into maintenance measured in months. The units differ between the phases and so does what the authorization actually covers. A maintenance dose billed against an authorization written for the loading schedule denies, and because the interval is long, it denies well after anyone remembers booking the chair.
- Loading and maintenance tracked as one course rather than as unrelated visits
- Units checked against the phase of the schedule the patient is actually in
- Interval eligibility confirmed before the appointment is made, not after it happens
The wrong code family denies a perfectly correct drug
Neurology infusions sit between two CPT families: the complex biologic set beginning at 96413 and the ordinary therapeutic set beginning at 96365. Which family a given product belongs to for a given payer is not a clinical question, and getting it wrong denies the administration while the drug line sails through untouched. It is a quiet, expensive error, because the administration is where the chair time gets paid for.
- Administration family determined per drug and per payer, not applied out of habit
- Additional hour codes supported by documented infusion time
- Administration denials read against the drug line rather than in isolation
A lapsed enrolment fails an otherwise clean claim
Natalizumab is dispensed under TOUCH, and other products carry their own restricted programs. Prescriber, site and patient enrolment all have to be current on the day of administration. None of it appears on the claim. All of it can invalidate one. Enrolments lapse at renewal, quietly, and the first sign is usually a denial for someone who has been infusing without incident for two years.
- Programme enrolment confirmed current before the infusion, not after the denial
- Renewal dates tracked rather than discovered
Grams, kilograms and vial sizes are three different numbers
Immunoglobulin is ordered by weight in grams, billed in fixed increments, and supplied in vials that rarely divide evenly into either. That is two conversions and a remainder before anything reaches a claim. Brands are not freely substitutable to a payer either, so a product swap at the pharmacy that nobody mentioned to billing becomes a denial nobody can account for.
- Weight-based order converted to billable units and checked against vials actually drawn
- Wastage documented and reported rather than written off
- Product substitutions caught before submission rather than in the remittance
Payers keep moving these infusions out of the hospital
Site-of-care policy has been pushing infusions from hospital outpatient departments into offices, ambulatory suites and the home for years, and it has not finished. Where the infusion happens changes what is payable and by how much. A policy that shifted since the last authorization is a denial sitting on the next appointment, and the schedule is usually built before anybody checks.
- Site-of-care policy checked per payer before scheduling
- Place of service on the claim reconciled against where the infusion actually happened
This is what we watch for. How the engagement runs is a separate question.
Before any of it applies to your practice we read your aged A/R and the last quarter of remittance advice, and you get the findings in writing including what we think is not worth chasing. You keep your practice management system, your payer contracts and your NPI throughout.