Oncology billing is drug billing, and drug billing is arithmetic. Units are calculated from the dose administered, and a mismatch between the dose in the note and the units on the claim is one of the most common causes of both denials and overpayment recovery.
Biosimilars add a second layer. Codes change as products enter the market and as payers change their preferred agent, so a code that paid last quarter may not be the right one this quarter.
What trips oncology claims up
- Drug units calculated from the dose administered, not the vial size
- Wastage documented and billed where the payer permits it
- Biosimilar substitutions matched to the correct code, which changes often
- Infusion time recorded so initial and sequential codes hold up
What we check before a claim goes out
- J-code units calculated from dose administered, not vial size
- Wastage documented and billed where the payer permits
- Infusion start and stop times recorded for sequential codes