Hematology Billing Services
Hematology & hematology-oncology billing that protects high-value drug revenue, streamlines infusion claims, and reduces denials so clinicians can treat patients, not paperwork.
Your practice manages complex diagnostics, lifesaving transfusions, infusions, and often high-cost biologic drugs. One small coding or unit error can delay tens of thousands in reimbursement. At Sirius Solutions Global we combine hematology-specific coders, infusion & transfusion billing expertise, and AI-powered automation so you collect more, appeal smarter, and keep your clinicians focused on patient care.
End-to-End Hematology RCM
We’re not just a claims shop. We’re a revenue partner.
Eligibility, benefit & prior-authorization workflows
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Verify benefits for infusion drugs, DME, and transfusions. Identify step-therapy, prior-auth or medical-necessity rules before infusion scheduling.
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Scrub benefit rules for Medicare vs commercial plans and Medicare Advantage nuances.
Accurate drug capture, J-code & NDC mapping
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Map each administered agent to the correct J-code and NDC, capture units and vials, and apply JW/JZ modifiers for wastage documentation when applicable. This reduces rejections and improves drug capture.
Procedure & surgical coding (bone marrow biopsies, central line placement)
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Properly code and split technical/professional components, attach pathology interpretation, and ensure operative/procedure notes support billed services (CPTs 38220–38241).
Infusion administration & supportive care coding
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Correctly pair administration CPTs (e.g., chemo/infusion admin codes where applicable) with drug lines; ensure documentation contains start/stop times, pump usage, and nursing notes required for admin codes.
Claims submission, payer-tailored templates & EDI
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Submit claims with payer-specific templates (including necessary NDC fields), track EDI rejections, and resubmit corrected claims quickly.
Denial management & appeals (root-cause focused)
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Perform denial clustering, find repeating patterns (e.g., same payer denying same J-code), and build targeted appeals (medical necessity letters, lot/NDC/infusion logs, physician addenda).
Clinical trial billing separation & sponsor invoicing
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Tag trial visits vs routine care, prepare sponsor invoices, and protect your practice from improper billing to commercial payers.
A/R management & KPI dashboards
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Weekly dashboards: drug capture rate, J-code denials, first-pass acceptance, days-in-A/R, net collection rate, and top denial drivers by payer/CPT. Actionable insights and monthly partnership reviews.
Compliance & audit readiness
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Audit-ready documentation bundles (infusion logs, NDCs, pump logs, consent for transfusion) and pre-bill checks to reduce recoupment risk.
Outcomes & KPIs you can expe
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Improve first-pass acceptance by 10–40% depending on baseline through AI scrubs + payer templates.
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Reduce high-value denials (J-code & infusion) through pre-bill checks and targeted appeals.
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Shorten days-in-A/R via priority scoring and focused follow-up on high-value items.
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Increase net collections by improving drug capture and reducing underpayments from mis-coded procedures.
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Lower cost-to-collect with automations that reduce manual biller hours.
Why hematology billing is different
Hematology billing isn’t “medical billing plus labs.” It mixes high-volume lab billing with high-dollar infusion and procedural claims that require specific expertise.
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High-volume lab CPTs & specialized procedures. Many hematology practices bill frequent CBCs, coagulation panels, and more complex lab tests and also bill bone marrow biopsies (e.g., CPTs 38220–38241) and pathology interpretation. Mistakes in lab panel vs component reporting or missing specimen identifiers slow payment.
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Infusions & J-codes. Hematology often overlaps oncology in the use of injectable biologics or supportive therapies billed with HCPCS J-codes. These claims require NDC/unit capture, vial counting, and occasionally wastage documentation (JW/JZ) small errors here cause big denials.
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Transfusion & specialty procedure billing. Transfusion CPTs (e.g., 36430–36460) and transfusion-related supplies need accurate unit reporting and proper linking to clinical justification.
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Clinical trials & research separation. Many hematology practices participate in trials; separating routine care charges from research-sponsored charges avoids audit exposure.
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Regulatory & payer nuances. Coverage rules for infused agents and transfusions vary by payer; local coverage determinations and prior-auth rules matter. Pre-authorization and documentation for medical necessity are often required.
Common hematology denial scenarios & our fixes
Scenario A — J-code denied for NDC mismatch or missing vial count
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Why it happens: Payer expects NDC or the billed units don’t match the administered dose/vials.
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How we fix it: Our pre-bill scrub checks NDC + unit consistency, attaches the NDC and vial count in the claim (or bundles a documentation packet), and applies JW/JZ modifiers where appropriate.
Scenario B — Transfusion claim denied for missing clinical justification
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Why it happens: Payer requires documentation of hemoglobin threshold, transfusion intent, or specific indication.
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How we fix it: We attach pre-transfusion labs, physician orders, and nursing transfusion checklists to the claim/appeal.
Scenario C — Bone marrow biopsy underpaid / miscoded
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Why it happens: Procedure CPT and physician interpretation were not linked correctly, or global period confusion.
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How we fix it: We ensure CPTs for aspiration/biopsy + pathology interpretation are split appropriately and documentation supports both technical and professional components.
Scenario D — Clinical trial visit billed to payer instead of sponsor
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Why it happens: Routine vs research charges aren’t separated.
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How we fix it: We tag research visits, route sponsor-billable charges to the sponsor, and keep routine care on the appropriate payer, avoiding audits.
Market & competitor snapshot what matters in hematology RCM
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Hematology billing involves high-volume lab codes, procedural codes (bone marrow biopsies), transfusions, infusion therapy, and when combined with oncology J-codes for infused drugs. Accurate CPT/J-code mapping and NDC/unit reporting for infusions are frequent revenue levers.
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Common denial drivers for hematology practices include: missing/incorrect J-code or NDC data on infusion claims, incorrect units/vials reported (including JW/JZ wastage rules), incomplete documentation for transfusions or procedures, and lab/diagnostic coding errors. Prior authorization and medical necessity documentation are frequent front-line requirements.
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The RCM landscape is moving rapidly toward AI + automation vendors and RCM leaders report AI as a top investment for improving first-pass acceptance, denial prediction, and automation of routine tasks. That trend is highly relevant for hematology practices that manage high-value infusion claims.
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Hematology practices that combine clinical billing expertise (hematology/oncology coders) with technology that enforces drug capture, NDC, and unit validation see the largest, quickest gains in net collections.
How our AI-Powered Billing helps hematology practices
We use AI to amplify human expertise not replace it. Here’s how AI materially helps hematology billing.
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Automated NDC extraction & unit validation
Optical / document AI and structured feeds extract NDCs, vial counts, dose amounts, and link them to the J-code line preventing unit mismatches that cause denials. Studies and industry write-ups show automation improves capture and reduces manual hours. -
Pre-submission risk scoring for high-dollar infusion claims
ML models predict denial probability and expected dollar loss for each claim; high-risk claims are routed to clinical coders for pre-bill correction, keeping costly denials out of the backlog. This prioritization increases first-pass acceptance and reduces days-to-pay. -
Smart appeals & document assembly
AI pulls accession logs, infusion pump reports, nursing notes, and physician attestations into an audit packet that supports appeals saving hours of manual assembly and improving appeal success rates. -
Continuous payer rule monitoring
AI agents scan payer bulletins and LCD updates and push recommended scrub updates to the rules engine so your claims align with the latest local coverage decisions. This reduces errors caused by policy lag. -
Denial-pattern detection & automated corrective workflows
The system clusters denials by root cause (same CPT/payer/provider pattern) and auto-generates remediation tasks (rule update + staff retraining + documentation template change), so the same denial doesn’t repeat.
Bottom line: AI saves time and recovers revenue by catching the exceptions that matter; your coders and clinicians provide the clinical judgement.
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