Oncology Billing Guide: Infusion Services, Drugs, and Cancer Care
Cancer care is one of the most complex areas in terms of both financial and administrative aspects in modern healthcare. Between high-cost chemotherapy drugs, evolving payer rules, variations in infusion site pricing, and value-based models, oncology billing presents unique challenges. For providers and billing teams, accuracy is not just about revenue capture; it is essential to keep care sustainable for patients and practices alike. This oncology billing guide covers coding and compliance, economic costs, infusion site dynamics, and policy factors that shape the future of oncology reimbursement in the United States.
Coding and Billing for Infusion Services, Drugs, and Cancer Care
Oncology billing begins with precise coding. Chemotherapy and therapeutic infusions require separate CPT codes, each tied to specific administration rules.
| Chemotherapy & Infusion CPT Codes | ||
|---|---|---|
| Category | CPT Codes | Description |
| Chemotherapy - Initial Hour | 96413 | IV infusion, up to 1 hour |
| Chemotherapy - Additional Hour | 96415 | Each additional hour beyond initial |
| Prolonged Infusion | 96416, 96417 | Infusions beyond 8 hours or subsequent prolonged infusions |
| Therapeutic Infusion - Initial | 96365 | Initial IV infusion, upto 1 hour |
| Therapeutic Infusion - Add’l | 96366 | Each additional hour |
| Sequential Infusion | 96367 | Infusion of a different drug/substance, sequential |
| Concurrent Infusion | 96268 | Infusion of multiple drugs/substances at the same time |
Modifiers also play a central role in oncology billing. For instance, JW is required to document drug wastage from single-use vials. Compliance also demands strict sequencing where chemotherapy is always billed first, therapeutic infusions second, and hydration last. Accurate start and stop times must always be documented to validate billed hours, while additional codes like 99497 may apply when advanced care planning is provided.
| Oncology-Related ICD-10 Codes | ||
|---|---|---|
| Category | ICD-10 Codes | Description |
| Cancer-Specific Codes | C00 - C97 | Malignant neoplasms (location-specific cancers) |
| Encounter for Chemotherapy | Z51.11 | Visit for a chemotherapy session |
| Encounter for Immunotherapy | Z51.12 | Visit for an immunotherapy session |
| Encounter for Radiation Therapy | Z51.0 | Visit for a radiotherapy session |
The Economic Burden of Cancer Care in the U.S.
Cancer treatment is not only physically and emotionally demanding, but it also carries an enormous financial strain for patients and their families. Recent research highlights how the economic weight of cancer care has intensified in the United States, with rising drug prices, out-of-pocket expenses, and systemic inequalities creating long-term challenges for survivors.
A 2025 JAMA Network Open study analyzed data from over 46,000 cancer patients and found that out-of-pocket healthcare costs rise by an average of $592 per month during the six months following a diagnosis, totaling more than $4,100 per patient. The burden varies by stage: patients diagnosed with stage 0 cancers faced an increase of $462 per month, while those at stage 4 bore an additional $720 per month. These numbers underscore how quickly financial strain sets in after diagnosis.
Beyond initial treatment, the financial impact of cancer care lingers. Nearly 60% of working-age cancer survivors report some form of financial hardship, whether that means struggling to pay medical bills, delaying care, or even forgoing treatment altogether.
Drug costs compound the issue: more than half of cancer drugs introduced between 2019 and 2023 carry price tags of at least $200,000 per year. For example, Imbruvica, a leukemia drug, lists at $213,000 annually, with Medicare patients still paying an average of $5,247 out-of-pocket in 2022.
This widespread financial distress has been labeled “financial toxicity.” Adults with cancer are 71% more likely to experience financial problems than those without, and for some, treatment costs consume over 20% of their annual income. The consequences can be devastating, ranging from bankruptcy and job loss to delayed treatment and housing insecurity.
Adding to the complexity, drug pricing disparities across the country create unequal access. For instance, the prostate cancer drug Zytiga costs $815 in northern Michigan under Medicare, but $3,356 in other regions due to opaque pharmacy benefit manager (PBM) negotiations. Such disparities highlight how systemic pricing structures amplify inequities in cancer care affordability.
Overall, these updated statistics paint a sobering picture: while cancer therapies continue to advance, the financial realities for patients are worsening. From escalating drug costs to hidden out-of-pocket expenses, cancer’s economic burden is reshaping patient care decisions and long-term survivorship in America.
Infusion Site and Pricing Dynamics
Where patients receive infusion therapy has a direct impact on cost. Most infusions occurred in ambulatory settings throughout 2017 to late 2023, increasing from 59% to 63%. Hospital outpatient departments accounted for 35 to 38 percent, while home infusions declined from 3.1 percent to just over 2 percent.
The cost differential between sites is substantial. Biologic and chemotherapy infusions in hospital outpatient departments are often nearly double the cost of those in physician offices, while hormonal therapies can be 68 percent higher. Community oncology settings have been shown to deliver infusions up to 35 percent cheaper, collectively saving the healthcare system an estimated $1.3 billion.
For Medicare patients, chemotherapy administered in a physician’s office has historically cost $6,500 less per patient compared to hospital outpatient settings. Yet despite these cost savings, site-of-care shifts remain gradual, leaving significant opportunities to improve efficiency.
Value-Based Models and Policy Factors
Policy frameworks and alternative payment models increasingly shape billing and reimbursement in oncology. The Oncology Care Model (OCM), introduced by CMS, established six-month chemotherapy episode payments that combined traditional fee-for-service with monthly care management fees and performance-based incentives. At its peak, OCM involved nearly 190 provider groups and more than 3,000 physicians, setting the stage for more outcomes-driven oncology payment approaches.
The 340B Drug Pricing Program adds another layer of complexity. Intended to provide discounts on drugs for hospitals serving vulnerable populations, the program has been criticized for allowing hospitals to retain financial gains while billing insurers at significantly higher rates. Studies have shown that large 340B hospitals may charge 35 percent more for outpatient services than non-340B facilities, a factor that can increase coinsurance costs for patients and employer spending.
Administrative overhead is another critical policy concern. In the U.S., as much as 25 percent of healthcare costs are tied to administrative expenses, compared to just 10 to 15 percent in other developed countries. Streamlining administrative workflows in oncology billing could save billions annually and free up resources for direct patient care.
Key Takeaways for Oncology Practices
The data is clear. Oncology billing is not just about managing CPT codes and J-codes; it is about navigating an ecosystem of cost drivers, payer rules, infusion site pricing dynamics, and policy reforms. To thrive financially while delivering quality cancer care, practices should:
- Maintain precise documentation of infusion start and stop times, drug dosages, and sequencing of codes
- Stay updated on CPT, HCPCS, and ICD code changes through ongoing training
- Optimize site-of-care decisions, favoring community and physician office infusions where feasible
- Proactively secure prior authorizations and manage denials quickly to avoid cash flow disruption
- Explore value-based care participation to align reimbursement with outcomes and reduce financial risk
Conclusion
Oncology billing is uniquely complex, demanding both clinical precision and administrative expertise. With cancer care costs rising and reimbursement models evolving, practices must embrace meticulous coding, effective denial management, and cost-conscious site-of-care decisions. Partnering with expert billing services such as MaxRemind can help oncology providers stay compliant, capture full reimbursement, and ensure financial sustainability while keeping patient care at the center of operations.
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FAQs
- What are the most commonly used chemotherapy infusion CPT codes?
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The most frequently used chemotherapy infusion codes include 96413 for the first hour of intravenous infusion, 96415 for each additional hour, and 96416/96417 for prolonged or subsequent infusions. Proper documentation of start and stop times is critical for compliance.
- How are therapeutic infusions billed differently from chemotherapy infusions?
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While chemotherapy has its own set of codes, therapeutic infusions primarily use 96365 for the initial hour and 96366 for additional hours. Additional codes like 96367 and 96368 apply for sequential and concurrent infusions, making sequencing documentation very important.
- Why is drug wastage documentation important in oncology billing?
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CMS requires providers to use the JW modifier to report discarded amounts from single-use vials. Accurate wastage reporting not only ensures compliance but also protects practices from revenue loss during audits.
- How should oncology practices sequence their billing?
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The correct billing order is chemotherapy first, therapeutic infusions second, and hydration last. Improper sequencing can result in denied claims and compliance issues, which can directly affect reimbursements.
- Which ICD-10 codes are typically used in oncology billing?
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Oncology billing often requires both cancer-specific codes (C00–C97) and treatment-related codes like Z51.11 for chemotherapy and Z51.12 for immunotherapy. Regular updates make it essential for practices to stay current with ICD, CPT, and HCPCS changes.