Oncology & Hematology Billing Services

Oncology billing is unforgiving because a single infusion visit can generate several different kinds of charges at once: the drug itself, the administration of that drug, hydration or supportive agents, and sometimes lab work or imaging. Each of those lines follows its own coding rules, and a mistake on any one of them can deny the whole encounter. Add prior authorization for high cost drugs and biologics, and the revenue cycle for a cancer practice becomes one of the most detail heavy in medicine.
MedPlus RCM provides medical billing, coding, credentialing, and denial management for oncology and hematology practices, built around the way cancer care is actually delivered and documented.

Oncology & Hematology billing challenges

Chemotherapy and biologic administration coding follows a strict hierarchy. Only one service per encounter is billed as the initial service, and the hierarchy ranks chemotherapy administration above non-chemotherapy infusions, which in turn rank above hydration. Common administration codes include 96413 for an initial chemotherapy infusion and add-on codes such as 96415 for additional infusion time and 96417 for a sequential infusion drug. Billing a sequential or add-on code as the initial service is an automatic edit, and time based infusion codes require documented start and stop times.
Drug coding carries its own risks. Most chemotherapy and biologic drugs are billed with HCPCS J-codes, and the units on the claim must match the dose given divided by the amount in the J-code descriptor. Each biosimilar carries its own distinct HCPCS code, so a pharmacy level product substitution that is not reflected on the claim creates a code mismatch that denies. Discarded drug from single use vials must be reported with the JW modifier when there is wastage, or the JZ modifier when there is none, and that attestation is required on most high cost drug lines.
Prior authorization touches nearly every part of oncology care: the regimen, the drugs, the imaging, and radiation therapy. An approval for one regimen does not cover a mid-treatment substitution, a dose increase beyond the approved range, or an added supportive agent. Radiation therapy adds a further split, with treatment planning and delivery coded separately and professional and technical components that must be billed by the right party. A claim that pairs a chemotherapy administration code with a history of cancer diagnosis instead of an active malignancy diagnosis will also mismatch and deny.

What MedPlus RCM handles for oncology & hematology practices

• End-to-end medical billing. Charge entry, claim scrubbing, submission, payment posting, and patient billing, the full cycle.
• Medical coding. Certified coders assign current ICD-10, CPT, and HCPCS codes matched to your documentation and specialty.
• Provider credentialing and enrollment. End-to-end enrollment with commercial payers and Medicare, plus re-credentialing maintenance.
• Denial management and recovery. Every denial investigated to root cause, corrected, and appealed with documentation.
• A/R recovery. Aged and outstanding balances audited and pursued, including balances already written off where the appeal window is still open.
• Financial reporting. Clean claim rates, collections, denial patterns, and A/R aging visible by payer and provider.

We serve oncology and hematology practices nationwide, including community cancer centers, hospital based clinics, and independent practices, across infusion therapy, radiation oncology support, and benign and malignant hematology.

Results oncology & hematology practices can check

MedPlus RCM maintains a 99% clean claim rate and keeps client accounts receivable under 30 days. Pricing is a performance-based percentage of successfully collected revenue: if you don’t get paid, we don’t get paid. We are 100% HIPAA compliant, and onboarding takes 2 to 4 weeks depending on practice size, with no disruption to your daily cash flow.

Frequently asked questions

Why do oncology claims deny so often?
The most common causes are administration hierarchy errors, missing wastage modifiers, unit mismatches on J-code drugs, and missing or lapsed prior authorization. Each of these is a documentation and sequencing problem, not a clinical one, which is why they are preventable with the right checks before submission.
What is the JW and JZ modifier rule?
When a drug comes in a single use vial, the claim must attest to what happened to the unused portion. JW reports discarded drug, and JZ reports that there was no discarded drug. Missing this attestation on a high cost drug line is a frequent denial trigger.
Do you handle prior authorization for chemotherapy regimens?
Yes. We verify authorization before treatment, track authorization scope against the regimen actually given, and flag changes such as drug substitutions or dose increases that need a new or amended authorization.
How do you code a visit with multiple infusions?
Only the highest ranked service is billed as the initial service, and the rest are billed as sequential, concurrent, or add-on services according to the documented order and timing. Start and stop times and the sequence of drugs in the infusion record drive that coding.
Can a biosimilar be billed under the reference product code?
No. Each biosimilar has its own HCPCS code, and the claim must reflect the exact product dispensed and administered.

Get a free financial audit

Find out where your oncology or hematology practice is losing revenue. Request a free financial audit and our specialists will review your claims, denials, and A/R.
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