Oncology billing is complex: chemotherapy administration hierarchies, high-cost drugs with strict unit reporting, and frequent payer authorization requirements.
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Oncology billing is complex because chemotherapy administration follows strict hierarchies and infused drugs are often the most expensive line on any claim in medicine. One wrong unit, a missing NDC or a drug given without authorization can mean a five-figure write-off.
Payers also check each regimen against their drug policies and the compendia, require specific diagnosis codes for each drug, and update drug payment rates every quarter. Radiation oncology adds treatment planning, simulation and weekly management codes with their own rules.
We bill medical and radiation oncology from the treatment plan and administration record, manage prior authorizations for every regimen, report waste correctly and follow up on every drug denial with the clinical criteria the payer requires.
Also see our medical coding, denial management, eligibility verification and revenue cycle management services.
Oncology claims pair administration codes with drug codes, and radiation oncology adds its own course-of-treatment codes.
| Code | Description | What we watch for |
|---|---|---|
| 96413 | Chemotherapy administration, IV infusion, up to 1 hour, single or initial drug | Highest-ranking administration service; only one initial service per encounter in most cases. |
| 96415 | Chemotherapy administration, IV infusion, each additional hour | Requires more than 30 minutes beyond the first hour, supported by start and stop times. |
| 96417 | Chemotherapy IV infusion, each additional sequential infusion of a different drug | For a second chemotherapy drug given after the first through the same access. |
| 96409 | Chemotherapy administration, IV push, single or initial drug | Pushes are 15 minutes or less; use 96411 for each additional drug by push. |
| 96401 | Chemotherapy administration, subcutaneous or intramuscular, non-hormonal anti-neoplastic | Use 96402 for hormonal anti-neoplastics such as leuprolide. |
| 96523 | Irrigation of implanted venous access device for drug delivery | Only reportable when no other service is performed on that day. |
| J9271 | Injection, pembrolizumab, 1 mg | Units equal milligrams given; payers check indication and line of therapy. |
| J9035 | Injection, bevacizumab, 10 mg | Biosimilars are billed with their own Q-codes; check payer preferred product lists. |
| 77263 | Therapeutic radiology treatment planning, complex | Reported once per course of treatment. |
| 77427 | Radiation treatment management, 5 treatments | Billed per 5 fractions; 3 or 4 remaining fractions at the end count as a unit. |
Code descriptions are summarized. CPT® is a registered trademark of the American Medical Association. Coverage and payment rules vary by payer and change every year; we code to the current code set and your payers’ policies.
Drug amount discardedReports drug discarded from a single-dose vial on its own line.
Zero drug wastedRequired by Medicare when no single-dose drug was discarded.
Clinical trial servicesQ0 for investigational items and Q1 for routine costs in a qualifying clinical trial.
Significant, separate E/MFor a visit that goes beyond the pre-chemotherapy assessment on a treatment day.
Distinct procedural serviceWhen two initial administration services are justified by separate access sites.
The denial reasons we see most often in oncology billing, with the claim adjustment reason code (CARC) payers usually attach, and what we do so they don't happen again.
Most commercial and Medicare Advantage plans require prior authorization for chemotherapy and immunotherapy drugs.
How we prevent it: We authorize the full regimen, track approved drugs, units and dates, and renew before approvals expire.
Payers deny drugs when the indication is not supported by their policy or the compendia.
How we prevent it: We check each drug against payer policy and the documented diagnosis, stage and prior treatment.
Drug lines without NDCs, or with units that do not match the dose, are rejected or underpaid.
How we prevent it: Units are calculated from the dose given, and NDCs come from the administration record.
Hydration given with chemotherapy, or a second initial service, is bundled under the hierarchy.
How we prevent it: We apply the infusion hierarchy and only report hydration when separately necessary.
Billing a secondary malignancy instead of the primary, or a history code during active treatment, causes mismatches.
How we prevent it: Coders confirm primary and secondary sites and active treatment status from the oncology notes.
From the first eligibility check to the final patient payment, one dedicated team handles every step and reports back to you.
We verify coverage, benefits, copays and deductibles before the visit. For oncology, that includes regimen-level prior authorizations and financial counseling for drug costs.
Our coders review documentation and assign CPT, HCPCS and ICD-10-CM codes to the highest supported specificity. Administration, drugs and radiation services are coded from the treatment plan and nursing record.
Every claim is checked against NCCI edits, payer policies and modifier rules before it goes out electronically, so it is paid on the first pass.
We post ERAs and EOBs, compare payments to your contracted rates and flag underpayments for appeal.
Every denial is worked: corrected, appealed or escalated, with root causes fed back to the front end. Drug denials are appealed with pathology, staging and compendia support.
You get clear monthly reports on collections, denials and A/R aging, and patients get easy-to-read statements and answers to billing questions.
Rules that change how oncology claims must be coded, documented and submitted.
Administration hierarchy: chemotherapy and complex biologic administration rank above therapeutic infusions and hydration.
Drug pricing: Medicare pays most Part B drugs based on average sales price, updated every quarter.
Clinical trials: routine costs need modifier Q1, diagnosis Z00.6 and the trial’s NCT number on the claim.
Radiation courses: planning, simulation, physics and weekly management codes each have per-course or per-week limits.
Send us a sample of your oncology denials and A/R. We'll show you where revenue is slipping and how we'd fix it, with no obligation and no upfront fees.