infusion and injection coding

8/19/2019 Infusion and Injection Coding

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Presented by:

Vivian Blankemeier, CCSPatricia Vargas, CCS

Prepared by:

Christi Gonzales, CCS


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Codes for injections and infusions compriseonly five pages of the more than 700 in theCPT manual, yet they continue to be amongthe most difficult for coders to decipher.


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Review of Concepts

Hierarchy

Code Definitions

Documentation

Time

Physician Order

Substance Administration

Concurrent vs. Sequential Infusion

Hydration

Tips/Exercises


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The CPT guidelines and hierarchy must befollowed:◦ One code in each category of intravenous infusion and injection

drug administration codes designated as the “initial” service.

◦ Order of service delivery does NOT determine what is “initial”.

◦ Typically only one “initial service” will be reported per encounterunless there is more than one IV access site.

Chemo services are primary to therapeutic, prophylactic, and diagnosticservices, which are primary to hydration services.

Infusions are primary to pushes, which are primary to injections.

The hierarchy does not apply to physician reporting.

The hierarchy does not apply to SQ/IM injections, only intravenousinjections.


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Facility coding of the “Initial” code should beselected using the hierarchy below:◦ Chemotherapy Infusions◦ Chemotherapy Injections◦ Therapeutic, Prophylactic and Diagnostic Infusions◦ Therapeutic, Prophylactic and Diagnostic Injections◦ Hydration Infusions

When coding injections and infusions, always followthe hierarchy regardless of the order in which services

were provided. Chemotherapy services are alwaysprimary, meaning you must report them first.


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Infusion Therapy 96365-96368◦ For purposes of facility coding, an infusion is required to

be more than fifteen (16+) minutes for safe and effectiveadministration.

Injection/IV Push Therapy 96374-96376◦ An intravenous injection (IV push) is an infusion of

fifteen minutes or less.

Hydration Therapy 96360-96361

IM/Subcutaneous Injection 96372


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Codes Description Time Duration

96360 Intravenous infusion;Hydration; initial, 31minutes to 1 hour

31 minutes to onehour

Do NOT reporthydration infusionsof 30 minutes orless

96361 Intravenous infusion;Hydration; eachadditional hour

Beginning at 91minutes

96365 Intravenous infusion;for therapy,prophylaxis, or

diagnostic; initial, upto 1 hour

16 minutes to onehour

Infusion less than

15 minutes = IVP


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96366 Intravenous infusion,for therapy,prophylaxis, ordiagnostic; eachadditional hour (listseparately in addition

to primary code)

Beginning at 91minutes

Same Drug

96367 Intravenous infusion,therapy, prophylaxisor diagnostic;additional sequentialinfusion, up to 1 hour

(list separately inaddition to primarycode)

Different Drug Additional hours

will be reportedusing 96366


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96368 Intravenous infusion,for therapy,prophylaxis, ordiagnostic; concurrentinfusion) listseparately in addition

to primary code) ONCEper day

16 to 90 minutes Can only be billed

ONCE regardless of the duration of theconcurrent infusion

96372 Subcutaneous or IMinjection

No restrictions onmultiple injections

96374 Therapeutic,prophylactic or

diagnostic injection;IVP, single or initialsubstance/drug

15 minutes or less Do NOT report this

with InitialTherapeuticInfusion (96365)unless meetscriteria


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96375 Therapeutic,prophylactic ordiagnostic injection;each additionalsequential IV PUSH of

a NEW substance/drug(list separately inaddition to code forprimary procedure

15 minutes or less NEW drug

96376 Same as Above exceptSAME drug

15 minutes or less SAME drug Must be 30 minutes

since initial push


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90460 – 90474

Code only one INITIAL immunizationadministration per visit

Follow same rules as injections/infusions

Parentheticals below immunization codes

clearly state which combinations are notallowed to be billed together


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IM or Subcutaneous Injections: 96372

Multiple IM/Subcutaneous Injections:◦

Same drug/substance can be reported as long as itis ordered and documented

◦ There are no time restrictions/guidelines present atthis time

◦ Documentation needs to be made of site and time


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Some answers:◦ Per AMA – “Infusion time is measured when the

infusate is actually running: pre and post time arenot counted. It is recommended to document

infusion start and stop times.”◦ Per CMS IOM 100-4, Chapter 4, 230 – “Hospitals are

to report codes according to CPT instructions. CPTinstructions are to use actual time over which theinfusion is administered to the beneficiary for time-specific drug administration codes.”

◦

CMS – Indicates that it has the expectation thathospitals will document time otherwise CMS has adifficult time understanding how services would bebilled appropriately.


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Physician and nursing documentation are thekey for accurate charging.

Typically, hospital documentation for infusion

services reflect the substance being infusedand the flow rate…but this is not enough.

Drug administration services that referencetime are in fact

“time based”

codes, therefore

documentation should support the billedcharges.


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Time Documentation is Critical and Drives theAccuracy of the Codes Reported:◦ Less than 15 minutes

◦ More than 15 minutes (16+)

◦

31 minutes to 1 hours◦ 15 to 90 minutes vs more than 90 minutes (91)

◦ 30 minutes since the last reported push

◦ Greater than 30 minutes beyond 1 hour increments(91)


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The infusion time is defined as the actualtime over which the infusion is administered.Infusion time is calculated from the time theadministration commences (i.e., the infusionstarts dripping) to when it ends (i.e., the

infusion stops dripping).

Intravenous or intra-arterial pushadministration are differentiated from theother infusion services and defined as“infusion of 15 minutes or less”.


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Billing and Coding for Infusions need:

◦ Name of the Drug

◦ Strength of the Drug

◦

Method of Administration◦ Time-Time-Time


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The Rules for Documentation

◦ Must be ordered by a physician

◦ Documentation must support medical necessity

◦

EACH substance administered is: Clearly documented, no abbreviations

Route and Site are easily discernible

Start and stop times for EACH substance aredocumented

This is the best practice

Amount of EACH substance given is documented


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Sometimes It’s OK to Have More Than One

Initial or Primary Service Code

Separate Site Separate Encounter

2 am

4 pm

To report 2 different “initial” service

codes use Modifier -59.


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A Concurrent Infusion

occurs when multiple

infusions are provided

simultaneously through

the same intravenousline.


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Sequential is one after the other through thesame venous access site.

Concurrent is at the same time through thesame access site (but may be through adifferent lumen of the catheter).

Multiple drugs added to one bag of fluids areNOT a concurrent infusion.


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Hydration is considered an infusion of prepackaged fluid for the purpose of restoringbodily fluid. There must be physiciandocumentation of medical necessity to charge forhydration. This includes but not limited to:

Dehydration/Volume Depletion

Inability to maintain fluid intake (i.e., nausea &/vomiting)

Sugar &/ electrolyte imbalances

Diarrhea

Pain

*NOTE: Hydration cannot be reported for TKO, KVO, Heplock, Saline Lock


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Only one “initial” service code should be reported, unless twoseparate IV sites are required;

Hydration codes are reported after 30 minutes of infusion(31)/Do not charge hydration when provided for 30 minutes orless;

Concurrent infusion is only reported once per encounter; Sequential is one after the other; concurrent is at the same time.

In order to report a concurrent administration, the drugs cannotsimply be mixed in one bag; there must be more than one bag; Infusions of 15 minutes or less are reported with an IV push

code; Injections are coded per injection, not per medication; Each additional sequential IV push of the same substance must

be greater than 30 minutes;

Vaccination codes utilize an administration code 90465-90474in addition to the vaccine/toxoid 90476-90479;


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Do not charge for hydration and infusion during the sametime interval;

Hydration consists of pre-packaged fluid and electrolytes(e.g., normal saline, D5 ½ normal saline + 30 mEq KCl/liter);

Do not charge for services integral to a procedure (e.g., drugs

given during CPR or prior to intubation);

Infusion is for the administration of substances/drugs. Whenfluids are used to administer the drug(s), the administrationof the fluid is considered incidental hydration and is notseparately reportable;

Hydration is not coded on a concurrent service.


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Contrast Epinephrine Surgery

during during CPR or

CT Scan Recovery


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If performed to facilitate the infusion orinjection, the following services are includedand are not reported separately:◦ Use of local anesthesia

◦

Intravenous (IV) start◦ Access to indwelling IV, subcutaneous catheter or

port

◦ Flush at conclusion of infusion

◦ Standard tubing, syringes and supplies

◦

Preparation of the chemotherapy agent(s)


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To begin, select one column based on the facility

hierarchy whereby infusion is first, IV push is second and

hydration is third. Mark all remaining charges in that

column. If a patient does not receive an IV infusion, start

with the IV push column. If a patient does not receive aninfusion or an IV push, start with the hydration column.


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MEDICATION INFUSION

____96365 Initial Infusion

up to 1 hour

____# hours 96366 Each

add’l hour (after 31 min)

____ 96367 Sequential

infusion up to 1 hour (use

96366 for add’l hours of

sequential infusion)

____96368 Concurrent

infusion – Report only onceper encounter

____ 96375 IV Push Each

push of different drug

____ 96376 Each IV push

of same drug at intervals >30

min

____ hours 96361Hydration – Do not charge

during same time of infusion,

must be at least 31 min

____ 96372 IM SQ

injection

____90471 IM SQ vaccine

IV PUSH

____96374 Initial Push or

Infusion 30

min

____ hours 96361

Hydration – Must be at least

31 minutes

____ 96372 IM SQ

injection


____ 90472Each add’l

IM SQ vaccine

HYDRATION

____96360 Initial hydration

up to 1 hour – must be at

least 31 min

____ hours 96361

Hydration Each add’l hour

(after 31 min)

____ 96372 IM SQ

injection


____ 90472Each add’l

IM SQ vaccine


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Jane Smith comes into the ER with vomiting.

Dr. Roberts orders an IV push of Zofran and IVhydration for dehydration. The nursedocuments that she administered the IV push at1:44 p.m. She also documents that she startedthe hydration at 2:05 p.m. and discontinued itat 4:10 p.m. How do you code theinjections/infusions on this case?


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96374 – IVP

96361 x 2 - Hydration


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A 66-year-old patient arrives to the ER andreceives a therapeutic infusion from 10:15am to 11:55 a.m. The patient receives an IVpush of the same drug at 1:00 p.m.

How is this reported?


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96365 – 1st hour of infusion

96366 – 2nd hour of infusion

96376 – IVP of the same drug


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A 54-year-old patient comes to the ERcomplaining of pain in his legs and backsaying he feels nauseous and lightheaded.The ER starts an IV and begins hydration from

7-7:25 a.m. and IVP of Morphine is given at8:00 a.m.

How is this reported?


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96374 – IVP of Morphine

No code is assigned for the hydration sincethe time is less than 30 minutes.


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Patient has the following:◦ Lasix IVP @ 10:00 a.m.

◦ Lasix IVP @ 10:25 a.m.

◦ Phenergan IVP @ 10:40 a.m.

◦ Lasix IVP @ 1:00 p.m.

◦ Lasix IVP @ 3:00 p.m.

◦ How is this reported?


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96374 x 1 – Initial IVP Lasix 96375 x 1 – IVP different drug (Phenergan)

96376 x 2 – IVP same drug (Lasix)

NOTE- Lasix IVP at 10:25 cannot be billedsince it had not been 30 minutes since initialpush.


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Patient presents to the ER in respiratoryfailure. Patient was administered an IVP of Etomidate at 0200 and was intubated. Patientwas placed on a ventilator and maintainedgood oxygen saturations. Patient’s heart rate

dipped to 50 but responded to IVP of Atropine at 0300. Patient infused withVancomycin from 0325-0435. Levaquininfused from 0345-0420.

How would this be reported?


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96365 – Initial Infusion of Vancomycin

96367 – Sequential Infusion of Levaquin

96375 – IVP Atropine (different drug)

Etomidate would not be charged sinceintegral to the intubation.


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