Article Reference Code: NAMAS.10.31.2025
Auditing Infusion in 5 steps
Written by: LaDonna Brown
Each audit has specific considerations. To begin, conduct thorough initial research to establish a solid foundation for subsequent steps. Key research areas should include reviewing current payer policies and recent regulatory changes. Additionally, familiarize yourself with emerging trends in infusion services and any updates to Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) guidelines. This research will provide auditors with the most current and relevant information to guide their work effectively.
Before each audit, review Current Procedural Terminology (CPT) codes and then validate charges for bundling, modifier use, payor policies, and alignment with Local Coverage Determination (LCD) and National Coverage Determination (NCD) guidelines.
During the audit of professional infusion services, determine whether an Evaluation and Management (E/M) service was billed on the same date as the infusion. For the E/M service to be justified, documentation must clearly explain why it is distinct from the infusion, such as addressing new or unrelated conditions, performing a thorough evaluation not required for the infusion, or providing decision-making beyond what is necessary for the infusion procedure.
- Begin with a review of medical documentation:
- Ensure the patient’s chart includes a physician’s order stating the drug, dose, and reason for administration.
- For each infusion day, confirm a complete flow sheet or record that documents the drug, administration details, timing, dosage, patient tolerance, and clinician identity to ensure accurate billing, coding, medical necessity, safety, and compliance
- Identify the Correct Codes
- Determine which CPT or HCPCS codes apply to the chemotherapy or infusion therapy given, such as initial, subsequent, or concurrent infusions.
- Sequencing Codes
- Review the CPT code hierarchy to ensure the primary infusion is listed, along with any additional codes for multiple drugs or hydration as required.
- Review Modifiers Used
- Verify that appropriate modifiers were used for special circumstances, including repeated procedures, bilateral services, or reduced services.
- Review the documentation for drug wastage and, if applicable, verify that the JW modifier was appended correctly.
- If a single-use vial was used during the infusion, ensure the JZ modifier was appended to the charge as required.
- Validate Payer Requirements
- Review the patient’s insurance payer to ensure codes, modifiers, and documentation meet their guidelines. Because payer requirements vary, regularly consult payer portals or industry resources for the latest information to support compliant audits.
Following these five steps supports compliance, patient safety, and quality infusion care. Careful planning, observation, and documentation also help identify risks early.
LaDonna Brown, CPC, CPMA, CEMA
LaDonna brings over three decades of experience in the medical field, specializing in Vascular Surgery, Interventional Radiology, Interventional Neurology, Family Medicine, Oncology, and Infusion services. With a strong multi-specialty surgical background, she has developed extensive expertise in clinical and coding operations. Since earning her Certified Professional Coder (CPC) credential in 2004, LaDonna has focused on ensuring physician compliance with medical coding, Medicare, and third-party payer guidelines. Her depth of knowledge and commitment to accuracy make her a trusted professional in healthcare compliance and reimbursement.
