Oncology Medical Billing Services —
Chemotherapy, Radiation & All Cancer Codes

When three drugs are administered, one is primary, and the others depend on timing and overlap. The most resource-intensive is the primary service. If all three are chemotherapy: (1) First agent — 96413 (primary chemo, first hour) + 96415 for each additional hour; (2) Second agent started sequentially (after first finishes) — 96417 (sequential chemo, first hour) + 96415 additional hours; (3) Third agent also sequential — another 96417 + 96415. If pre-medication or anti-nausea drug is infused concurrently: that's 96365 for first non-chemo infusion (if primary), or 96367 for each concurrent drug running simultaneously with the primary. The hierarchy is determined by the nursing infusion record — start times, overlap, and drug identity.

Authorization for drugs like pembrolizumab, nivolumab, trastuzumab, and CAR-T therapies requires comprehensive clinical submissions: pathology with biomarker results (PD-L1 expression, MSI status, HER2 status), staging documentation, prior therapy history, and evidence-based clinical guideline citations (NCCN, ASCO). We maintain indication-specific auth templates for every major oncologic agent, updated when FDA expands indications or when NCCN guidelines change. Auth requests are submitted with the complete package — not a one-page clinical summary — which reduces initial denial rates substantially. When denials occur, we file peer-to-peer requests within 48 hours.

Under the Medicare Clinical Trial Policy (NCD 310.1), Medicare covers routine costs of care for qualifying clinical trials. Routine costs include: services that would be provided regardless of trial participation, services for management of complications arising from participation, and services needed for reasonable and necessary care. NOT covered by Medicare (must bill to sponsor): investigational items, items provided solely for data collection, and services that exceed standard care requirements. Our approach is to document the billing segregation in writing before the first patient is enrolled, map every service in the trial protocol to either "routine care" or "trial-required," and review every trial patient's claims against that map before submission.

In-office infusion billing (POS 11) generates the full professional fee including the administration service — the practice is paid for both the drug and the administration work. Hospital outpatient department (HOPD) billing (POS 22) generates the professional fee at the facility rate (lower than non-facility), while the hospital separately bills the facility fee. When the same drug is administered in both settings, the physician's billing must reflect the correct POS and rate for each location. We maintain separate billing configurations for each practice location and verify POS accuracy before every claim — a $300–$800 per-claim revenue difference between the two settings.

Oral oncologic drugs prescribed and administered in the office use HCPCS codes billed on the medical claim. Oral drugs prescribed for patient self-administration (take-home) typically flow through specialty pharmacy and are billed under the pharmacy benefit, not the medical benefit. We handle in-office oral drug billing (e.g., temozolomide dispensed in the office) using the correct HCPCS codes with appropriate quantity documentation. For take-home prescriptions, we coordinate with your specialty pharmacy partner to ensure the transition from infusion to oral is documented in the medical record and that authorizations are in place before the first oral prescription.

Every drug HCPCS code has a unit size built into its descriptor — J9035 (bevacizumab) is billed per 10mg, so a 400mg dose is 40 units, not 4. We calculate every unit count from the pharmacy dispensing record and administered dose, not the order, and cross-reference it before submission. Separately, when a biosimilar is dispensed instead of the reference product — Mvasi (biosimilar bevacizumab) instead of Avastin, for example — it has its own Q-code (Q5119 for Mvasi vs. J9035 for the reference product). We maintain a current biosimilar-to-Q-code mapping updated with every new FDA approval, and code from the actual product dispensed rather than defaulting to the reference standard, which prevents documentation mismatches that look like upcoding on audit.

Yes, and it's one of the most commonly under-captured parts of an infusion visit. Pre-medications, anti-nausea drugs, hydration before nephrotoxic agents, and growth factors are all separately billable as concurrent infusion add-ons (96367) alongside the primary chemotherapy administration code. A well-coded infusion visit captures every concurrent drug that was actually administered, not just the primary chemotherapy agent — we build the full add-on set from the nursing infusion record for every visit.