Outpatient Infusion Movement Offers Additional Revenue Opportunity

Many infectious disease (ID) physicians are missing out on a potential revenue- boosting opportunity. ID specialists have made a dramatic move in the last several years to outpatient infusion suites as a way of maintaining continuity of care for their patients who otherwise would have been discharged from the hospital to home-health companies. The impact has been an incredible opportunity to receive reimbursement for the provision of additional services, ID experts say. Now, patients are spending less time waiting on home-health companies for service and, instead, are developing a one-on-one relationship with an infusion nurse and constant, face-to-face communication with their physician. Under this setup, physicians better control patient care by providing direct supervision and outcomes-monitoring of their patients.

Physicians offices with outpatient antibiotic therapy (OPAT) programs can almost eliminate the need for home-health companies. Non-ambulatory patients and those patients with whom they have no contract or cannot negotiate with their insurance company often represent less than 5 percent of the patients who require outpatient infusion. On average, 98 percent of our patients self-infuse but this varies widely by practice. Practices heavily saturated with Medicare patients that have Medicare supplemental policies as opposed to true secondary policies are forced to infuse these patients daily in the office for any insurance benefit, says Glenda Castro, a reimbursement specialist for San Antonio Infectious Diseases Consultants, an ID consulting firm in San Antonio, Texas. According to Castro, the commonly treated infectious diseases in this area are osteomyelitis (730.2), cellulitis (682.9), pneumonia (486.0), bacteremia/septicemia (038.9), and postoperative infections.

Coding for Outpatient Infusion

In general, Castro says, office-infused therapies are limited and fairly straightforward as far as coding goes. Use the J codes for drugs and codes 90780-90781 for infusion hours, says Castro. Infusion supplies generally are bundled with the infusion hours and not paid separately, she adds.

Home self-infused therapies require more creativity and attention to detail on the part of insurance carriers, Castro notes. Some carriers will allow infusion center contracting for the cost of the drug (acquisition wholesale price, more or less) and per diems that usually include nursing, line care and pharmacy mixing and dispensing, she explains.

The codes by which these per diems are billed vary by insurance carrier. We have contracts that require 99999, E0781 (ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient) and J3490 (unclassified drugs) for their per diem code, depending on the carrier, says Castro. Most carriers recognize the J codes for drugs, but if your contract is based on acquisition wholesale price (AWP), its best to also use the National Drug Code (NDC) so that the drug you are getting paid for is the drug you purchased. If the carrier pays [...]

- Published on 2000-06-01