Infusion and Injection Coding

1. Infusion and Injection Coding Kari M Keller, CCS, CPC-I PMCC Instructor for the AAPC Adjunct Professor for LFCC

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3. Time documentation is critical Start & Stop times are necessary to distinguish if the drug administered is initial, sequential, additional, and current. If the time is 15 minutes or less; report using an IV push injection code Initial or first hour of infusion is from 16 to 90minutes (applies to therapeutic infusions; does not apply to hydration) Initial or first hour for hydration infusion is >30 mins and <91mins If there is no stop time for hydration you cannot report anything!!!! Additional hours of infusion Report add-on codes for additional hours of infusion (beyond the first hour) only after more than 30 minutes have passed from the end of the previously billed hour In other words; 91 minutes allow an additional hour to be charged Documentation & Key Components

4. How is the initial service selected? Follow the rule of hierarchy: Chemo Infusion Chemo Injection Non-chemo Therapeutic infusions Non-chemo Therapeutic injections (IVPs) Hydration infusions Rules of Hierarchyfor �Initial�

5. Infusion Coding Definitions

6. Separate Site IV #1 Right Hand/Forearm IV #2 Left Hand/Forearm Separate Encounter ER visit at 8:00am ER visit again at 4:00pm Sometimes It�s Okay to Have More Than One Initial Service Code

7. Drug administration services are to be reported with a line item date of service on the day they are provided. In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than one calendar day. Medicare Claims Processing ManualChapter 4, Section 230.2

8. Initial Therapeutic Infusion, for therapy, prophylaxis, or diagnosis Time Duration: >15mins and <91min 96365 (2010 CPT) Remember: If time does not exceed 15mins it is consider an IV push!!! Therapeutic Infusion Initial Definition

9. Therapeutic Infusion Each additional hour (List separately in addition to primary Therapeutic Infusion Code) Time Duration: begin calculating time once it hits >90 mins See separate �Reporting Additional Hours of Infusion� 96366 (2010 CPT) Therapeutic Infusion Each Add�l Hour Definition (Each add�l hour of the same Drug)

10. Therapeutic Infusion Add�l Sequential, up to 1 hour (List separately in addition to code for primary Initial Therapeutic Procedure) Time Duration: Different Drug >15mins and <91mins 96367 (2010 CPT) Therapeutic Infusion Add�l Sequential Definition (Different Drug)

11. Sequential Infusion Definition : Initiation of different drug administered immediately following the initial infusion Note this is not exactly a true definition since sequential can refer to something that is administered �before or after� Report once per encounter for the same infusate mix; Note additional hours will be reported by using the therapeutic add�l hour infusion code ( 2010 CPT 96366) Therapeutic Infusion Add�l Sequential Definition Cont:

12. A concurrent infusion occurs when multiple infusions are provided simultaneously through the same intravenous line Therapeutic Infusion Concurrent (List separately in addition to code for primary Initial Therapeutic Infusion) Time Duration: >15mins and <91mins 96368 (2010 CPT) Therapeutic Infusion Concurrent Definition

13. Sequential is one after the other through the same venous access site. Concurrent is at the same time through the same access site (but may be through a different lumen of the catheter). Clinicians May Confuse Concurrent with Sequential

14. Benadryl and Cimetidine have been added to one bag of normal saline by our sterile products pharmacy. Is it appropriate to bill an administration code for each drug? Multiple Drugs Added to One Bag of Fluids is Not a Concurrent Infusion

15. *1 Zofran and Dexamethasone mixed in same bag and administered over 20 minutes prior to Chemotherapy *2 Chemotherapy given from 0800 to 1000. At 0830 Leucovorin is piggybacked into existing IV line and ends at 0930 *3 Infused banana bag with fluids, Thiamine, Folic acid and Magnesium *4 IV push bolus of heparin followed by heparin Drip Which of the following is correct use of a concurrent infusion?

16. Add-on Code/Charge for use when Multiple �infusions� are provided simultaneously through the same IV line, even with different bags. Think: �drugs given at the same time� Note: Multiple substances mixed in one bag are considered to be one infusion, not a concurrent infusion There is no concurrent code for hydration The concurrent CPT/Charge is limited to unit of one regardless of the duration of the concurrent infusion Therapeutic Infusion Concurrent Definition Cont:

17. Initial Intravenous Push substance/drug Time Duration: 15 minutes or less 96374 (2010 CPT) Do not report this charge/CPT with an Initial Therapeutic Infusion ( 2010 CPT 96365) unless it meets the following criteria's: REMEMBER: Protocols requires 2 separate IV sites Multiple encounters (account #) are provided on the same date of services Initial IV Push InjectionDefinition

18. Intravenous Push Each Additional (Same )Drug Time Duration: 15 minutes or less 96376 (2010 CPT) IVP is an infusion administered Multiple IVPs of the same non chemo substance/drug CAN be reported as long as at least 30 minutes has elapsed between each IVP of the same drug Example: Four hourly IVPs of Dilaudid would be reported as Initial IV Push (CPT 96374) x 1 IV push (Same) Drug (CPT 96376) x 3 as long as the elapsed times are 30 minutes apart. IV Push Each Add�l Same Drug

19. Intravenous Push each additional sequential (different) drug Time Duration: 15 minutes or less 96375 (2010 CPT) IV Push Sequential (Different) Drug Definition

20. There are many reasons and different diagnoses that may warrant an order for hydration, including diarrhea, nausea, vomiting, pain, dehydration, �etc Hydration is based on the solutions (pre-mixed, D5-W Normal Saline, Pre-mixed electrolytes, lactated ringer,..etc) Note !!! Hydration cannot be reported for the following: KVO Heplock Saline Lock Hydration Infusion Definition

21. Initial Hydration Infusion Time Duration: > 30 mins and <91mins 96360 (20010 CPT) Do not report this charge/CPT with an Initial Therapeutic Infusion ( 2010 CPT 96375) or Initial IV Push ( 2010 CPT 96374) unless it meets the following criteria's: Protocols requires 2 separate IV sites Multiple encounters (account #) are provided on the same date of services The time for the Hydration Infusion charge/CPT code cannot be reported if performed concurrent to an infusion (therapeutic) It is appropriate to charge for Hydration provided before and/or after Therapeutic infusion, but not the hydration time running at the same time as the Therapeutic Infusion. An intravenous infusion of hydration of 30 minutes or less cannot be reported If there is no stop time for hydration you cannot report anything!!!! Initial Hydration Infusion

22. Hydration Infusion Each Additional Hour Time Duration: begin calculating time once it hits >91 mins See separate �Reporting Additional Hours of Infusion� 96361 (2010 CPT 96361) The time for the Hydration Infusion charge/code cannot be reported if performed concurrent to an infusion (therapeutic) It is appropriate to charge for Hydration provided before and/or after Therapeutic infusion, but not the hydration time running at the same time as the Therapeutic Infusion Add�l Hydration Infusion Definition

23. IM or Sub Q Injections 96372 (2010 CPT) Multiple IM/SubQ Injections Same drug/substance can be reported as long as it is ordered and documented There are no time restriction/guidelines present at this time But on an audit stand point, please indicate the site and time the SubQ or IM injection was given Codes That Do not apply to the Hierarchy Rule

24. As far as the supplies that are used to administer the infusion, these are not separately billable as these are considered integral and/or inherent to the drug administration code. CPT further states: If performed to facilitate the infusion or injection, the following services are included and are NOT reported separately: Use of local anesthesia IV start Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion Standard tubing, syringes, and supplies Key Components

25. What about pre-operative injections/infusions? PER CCI EDIT MANUAL These are considered part of the operative procedure /services Do not report separately What about post-operative injections/infusions given in observation? May be charged only if the patient needs other medications that are unrelated to the procedure Definitions and Key Components

26. If a patient is receiving an IV infusion for hydration and the stop time is not documented in the record, how should that be coded? It would not be appropriate to report this as an IVP Reminder: Hydration 1st hour is 31 minutes to 90mins. Question #1

27. If the drug administration service is typically performed pre or post procedure, than do not separately report Example: Infusion of anesthetic for surgery Pre-op antibiotic injection/infusion Post op pain and/or nausea injections This also includes services provided in the Emergency Room Example: CPR But if the drug administration service is not typical for the procedure, then do report it separately Examples Anti-thrombolytic injection either pre- or post-surgery Anti- hypertensive injections Question #2

28. You have a patient in the ED and you are giving IV Push of Zofran every 5 minutes. Is it correct to charge 96374 x1 (Initial IV Push) and nothing for each additional because 30 minutes is not lapsing between each push? Correct- In order to be able to report 96376 (�IV Push Same drug) you need to have nursing documentation to support that a push of the same substance/drug was given 30 minutes apart. Question #3

29. When does infusion or chemotherapy administration begin- once you access vitals, place IV, and give pre-chemotherapy drugs? Answer: CPT Asst February 2009 17-21 Services up to and after are included. Time does not begin until the infusion starts dripping Question #4

30. If CT or MRI or other procedures with contrast are performed during same visit, and the infusate is not solely for the delivery of contrast, or the contrast itself, then infusion-injection should be charged and a modifier 59 added. Modifiers

31. A patient receives an IV infusion of Vancomycin (1st drug) for one hour and is considered the �initial� service.� This would be reported with CPT code 96365.� Then let�s say the patient received an additional sequential IV infusion of Ancef later in the day.� This is when you would use the code 96367 because it is of an additional sequential or �new� drug or substance.� If an IV infusion of the �same� drug is given multiple times during the same visit/encounter, you would add up the total infusion time.� Here�s a scenario: Example #1

32. IV infusion of Vancomycin � 0800 � 0900 Initial Therapeutic Infusion (CPT 96365) IV infusion of Ancef - 1000 � 1030 (� hour) ** IV infusion of Ancef � 1100 � 1130 (� hour) ** ** IV Sequential Therapeutic Infusion (CPT 96367) Because the Ancef is of the �same� infusate mix the 2 (� hour) infusions would be added together to equal 1 hour so you would report it with IV Sequential Therapeutic Infusion (CPT 96367).� If however, the total Ancef infusion ran for an additional 2 hours, you would report the additional 2 hours with the each additional hour code of IV Therapeutic Infusion Each add�l Hour (CPT 96366). Example 1 Answer

33. Patient has the following Lasix IVP Time: 1000 Lasix IVP Time: 1025 Lasix IVP Time: 1300 Lasix IVP Time: 1500 Example #2

34. Hospital would report the following 96374 x 1 - Initial IV Push 96376 x 2 - IV Push (Same Drug) Note you would not report the Lasix given at 1025 because the time did not elapse 30 mins between the Lasix IVP given at 1000 Example #2 Answer

35. Patient has the following: Morphine IVP Time: 1400 Demerol IVP Time: 1405 Morphine IVP Time 1500 Example #3

36. Hospital would report the following: 96374 x 1 - Initial IV Push 96375 x 1- IV Push Each Add�l (Different/New Drug) 96376 x 1 � IV Push (Same Drug) Example #3 Answer

37. Hydration of Normal Saline Time: 1515-1815 Demoral 25mg Time: 1515 Benadryl 25mg Time: 1517 Zofran IV second IV site and line Time 16:15-1715 Example #4

38. Hospital would report the following: 96365 x 1 Initial IV Therapeutic Infusion 96374 -59 x 1 Initial IV Push 96375 x 1 IV Push Each Add�l (Different/New Drug) 96361 x 3 Add�l Hydration Infusion Example #4 Answer

39. Questions?

40. Kari M Keller, CCS, CPC-I kkeller@lfcc.edu kari.keller@inova.org Phone: 540-436-3424 www.lfcc.edu www.aapc.com Contact Information: