Unravel injection and infusion coding confusion

Jane Smith comes into the emergency department with vomiting. Dr. Roberts orders an IV push of Zofran® and IV hydration for dehydration. The nurse documents that she administered the IV push at 1:44 p.m. She also documents that she started the hydration at 2:05 p.m. and discontinued it at 4:10 p.m. How do you code the injections and infusions part of this case?

For most hospital coders, charging or coding for these drug administration services is probably pretty easy. They would report CPT® code 96374 for the IV push and 96361x2 for the hydration.

Unfortunately, not all injection and infusion charging is so straightforward. Consider this example. Richard Jones comes in for a chemotherapy infusion. He first receives a nonchemotherapy IV push injection at 9:30 a.m. The nurse documents that the chemotherapy infusion runs from 11 a.m. to 12:45 p.m. In addition, he receives hydration from 10 a.m. to 12:45 p.m. How would you code this?

According to the CPT coding guidelines and the hierarchy for injections and infusions, you would code:

  • 96413 for the first hour of IV chemotherapy infusion
  • 96415 for the additional 45 minutes of the chemotherapy infusion
  • 96375 for the nonchemotherapy IV push injection
  • 96361 for the hydration

You may have wanted to code three units of 96361 since the hydration ran for two hours and 45 minutes. But remember, if hydration is running concurrently with another infusion, in this case the chemotherapy infusion, you cannot report it, according to CPT manual instructions.

“However, hydration that is medically necessary and provided before or after chemotherapy is appropriate to charge,” says Jugna Shah, MPH, president of Nimitt Consulting in Washington, DC. So in this case, if the documentation reflects that the physician ordered hydration for a medically necessary reason and not just to facilitate the administration of the chemotherapy, then you can report only the non-overlapping hydration time, which in this case is the first hour.

Coding injections and infusions
When coding injections and infusions, always follow the hierarchy regardless of the order in which services were provided. Chemotherapy services are always primary, meaning you must report them first.

Next, any code therapeutic, prophylactic, and diagnostic services, followed by hydration. When looking at the route of administration, first code infusions, then pushes, then injections. Note that the hierarchy does not apply to physician services.

CPT designates one code in each category of IV infusion and injection drug administration as initial. You will typically only have one initial code for each encounter unless the patient has more than one access site.

In addition, make note of the time element involved with coding drug administration services. Many of the codes specify a minimum amount of time required to assign the code and the provider needs to document that time. For example, to charge for hydration, it must run for more than 30 minutes.

To report additional hours of IV infusions using the add-on on codes, the infusion must run for more than 30 minutes beyond the last hour of infusion before you can report the additional time. So if an infusion runs for one hour and 20 minutes, you cannot report an add-on code. If the infusion runs for one hour and 31 minutes, you can report one unit of the add-on code.

“The AMA in CPT indicates that these are time-based services, and that documentation should reflect time,” says Valerie Rinkle, MPA, revenue cycle director for Asante Health System in Medford, OR. Both Shah and Rinkle agree that as time-based services, it’s clear that a best practice to support the use of these codes, especially additional hour codes is to have clearly documented start and stop times in the medical record.

Hydration reminders
If hydration lasts for 30 minutes or fewer, you cannot report it using the hydration CPT codes, says Shah.
Instead, you should report the hydration using the unlisted code 96379. Be sure to check with your fiscal intermediary or Medicare administrative contractor and other payers because some have indicated that coders should simply report hydration provided for less than 30 minutes with a revenue code and dollar charge.

What about hydration that is stopped and started multiple times? For example, if a patient receives two 25 minute hydrations, can you add the two sessions together and report a hydration code for the 50 minutes? Many years ago, when hospitals reported HCPCS Q codes, you would add the two separate hydration durations together and report the total time using the appropriate code. Not anymore, Shah says.

“Whether we’re talking about hydration or a therapeutic infusion, the rule of thumb is that each infusion, per its separate start and stop time, must be looked at on its own to see if it meets the time criteria,” Shah says. So in this case, you could not add the two hydrations together and report it.

Also remember that hospitals cannot report hydration when the fluids are solely to administer drugs or to keep a line open. The administration of fluid is incidental hydration and you cannot bill for it, Shah says. but don’t forget to report the saline/fluids which are packaged items but can be reported as supplies.

A patient does not need a diagnosis of dehydration to receive medically necessary hydration, Shah says. However, the physician must document the order for hydration and the medically necessary reason for the service, so an outside auditor can clearly tell why he or she did so.

IV push refresher
CPT defines an IV or intra-arterial push as “an injection in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient, or (b) an infusion of 15 minutes or less.”

Multiple codes exist for IV pushes. Base code selection on whether the push is initial or subsequent, and how much time elapses between multiple pushes of the same substance or drug. For multiple IV pushes of the same substance or drug, use code 96376, but only if 30 minutes elapse between the reported pushes. Note that this code is only for facility reporting of each additional sequential push of the same substance or drug. Again, coders cannot assign this code unless 30 minutes have passed since the prior injection of the same substance or drug.

For multiple intramuscular (IM) or subcutaneous injections, assign code 93672. This is the only code for these injections. When multiple IM or subcutaneous injections are administered, coders can report each of them.

Therapeutic infusion tips
When coding for therapeutic infusions, look for the documented time. The initial hour of an infusion is from 16 to 90 minutes. You cannot report an infusion code for those that run for less than 15 minutes even if the physician ordered an infusion and the drug was administered as such.

“Instead, the infusion service has to be reported as an IV push,” Shah says. That’s not always intuitive, especially for clinical staff. It also still causes problems for coders and nursing staff charging at the point of care.

If the infusion lasts for more than 30 minutes after the first hour, report the appropriate add-on code. That’s why coders think of 91 minutes, says Shah. “As soon as we’ve hit that mark, we know that we’ve got more than 30 minutes from the end of the last hour of infusion.”

Consider this example. Scott receives a nonchemotherapy therapeutic infusion that runs for 95 minutes. It is the only service rendered during the encounter. In this case, hospitals would report 96365 for the first hour and 96366 for the additional 35 minutes.

“This example clearly illustrates why time documentation is critical because without it, it will be difficult to justify to auditors that the use of the add-on code and payment received was appropriate,” Shah says.

Injection and infusion add-on codes
Think of subsequent and sequential codes as add-on services. They are provided one after the other or before or after the initial service. Use these codes in addition to an initial service.

When a patient receives a sequential infusion of a therapeutic drug, look at what infusate mix the patient received. If the same drug is given for more than 90 minutes, you can report the initial service and the sequential code. However, you can only report the sequential code once per infusate mix. If a different substance is infused, report the sequential infusion code for that substance.

Don’t make the mistake of getting locked in to one section of the injections and infusions codes. Drug administration CPT add-on codes don’t function in the same way as most other add-on codes do which is why you can use an add-on code even without having used the initial code describing that same service, Shah says.

For example, if you have hydration and an IV push, you would code the IV push (96374) as the initial service and report add-on code 96361 to report the hydration. You may believe you need to report 96360 before you can report 96361, but that is not the case with drug administration add-on codes. The exact codes will depend on the specific situation.

When multiple infusions are provided at the same time though the same IV line, look to the concurrent codes. Read the documentation to determine how many different sites are being accessed. Don’t focus on the number of drugs being infused or the number of different bags being hung—it’s the number of access sites that matter.

Don’t let the use of multi-lumen catheters fool you because they still use a single access site. This is why you have to look at how many different access sites to determine whether you can report multiple initial service codes. If drugs are administered through the same site, you would report the concurrent infusion code.

However, if a patient has an IV started in each arm, it would be considered two access sites. Report an initial service for each site and each subsequent service based on what the providers documented and actually administered through each specific site, Rinkle says. Append modifier -59 (distinct procedural service) to those codes for the second site.

“Always make sure you have the appropriate documentation before appending that modifier,” Rinkle says.

E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.

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