Injection and Infusion Coding Understanding the Basics Impact on ER’s, SDS, and OBS

1. Injection and Infusion CodingUnderstanding the BasicsImpact on ER’s, SDS, and OBS Lynda Starbuck, MS, RHIA Vice President – Coding Services HCCS Home Town Health – August, 2012

2. Disclaimer • HCCS makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. HCCS has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this presentation material, including but not limited to any loss of revenue, loss of business, or indirect damages resulting from the use of this presentation. HCCS makes no guarantee that the use of this presentation material will prevent differences of opinion or disputes with CMS or other third party payers as to the amount that will be paid to providers of service. • This information is based on the guidance available through June, 2012, but there are still many unanswered questions. Therefore, final decisions on how to report services to CMS must be taken by each individual hospital or healthcare system based on official information from their own FI /MAC and/or national guidance released by CMS.

3. 2012 Drug Administration • No operational impact (coding, billing impact). No CPT code changes for 2012. • Hospitals should continue following the CPT rules and hierarchy • Still no separate payment for multiple IV push injections of the same substance/drug (96376) or concurrent infusions (96368) • RAC audits will be performed related to time documentation and the use of modifier -59 with injection codes

4. 2012 Drug Administration continued… • 5 drug administration APCs continue, but payment levels have changed • Examine financial impact at the code level by comparing 2011 and 2012 payment rates • Some of the new text is questionable and not likely to be followed by CMS • Unanswered/open/controversial CPT coding questions remain… but we may finally see a new CPT Assistant in 2012 which is dedicated to drug administration “difficult-to-code” issues

5. Drugs/Infusion Services • J codes are used for billing specific drug costs and are reimbursable by CMS and other third party payers. • Infusion services (963xx codes) are coded and billed for the administration of drugs via IM, IVP, IVPB, etc. and the nursing staff time involved. J Codes/Drugs Administration Codes

6. Drug AdministrationAreas of Use • Reasonable and necessary • Safe, effective treatment if illness or injury (medical necessity) Outpatient Services only • Emergency Room • Ambulatory Surgery center (SDS) • Observation Services (OBS) CMS Covers if: Covered Services for:

7. Going Back in Timewith Injection & Infusion Coding • 2002 – Q0081 – one per visit • 2005 – 90780 – one per visit • 2007 – 90765 – initial service – 1 hour • 2009 – 96365 – initial service – 1 hour

8. Challenges Coders Facewith Injections & Infusions • Timed documentation • What is considered valid and complete documentation? • What should be reported when a stop time is not present? • What drug administration services are/are not considered integral to procedures? • Physician Documentation – there MUST be an order that is dated, timed and signed by the physician for the drug.

9. Challenges Coders Face continued… • If a significant, separately identifiable office or other outpatient Evaluation and Management service is performed, the appropriate E/M service (99201–99215, 99241–99245, 99354–99355) should be reported using modifier -25 in addition to 96360–96549. • A concurrent infusion is an infusion of a new substance or drug infused at the same time as another substance or drug. • A concurrent infusion service is not time based and is only reported once per day regardless of whether an additional new drug or substance is administered concurrently

10. Dates of Service • What happens when the visit/encounter crosses the midnight hour? • Report services using the actual date of service they were provided. • Codes should be reported for the entire encounter • You may see multiple lines of the same CPT code with different dates • Do not report multiple initial service codes because the patient stays overnight In transmittal 1702 dated March 13, 2009, CMS stated, “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.”

11. Challenges continued… • If intravenous hydration (96360, 96361) is given from 11 PM to 2AM, 96360 would be reported once and 96361 twice. However, if instead of a continuous infusion, a medication was given by intravenous push at 10 PM and 2 AM, as the service was not continuous, both administrations would be reported as an initial service (96374). Hospitals should not follow this per CMS and instead should continue to follow Medicare • Claims Processing Manual, 100-04, Ch. 4, Section 230.2, which states: Drug administration services are to be reported with a line-item date of services on the day they are provided. … hospitals should report only one initial drug admin service per encounter for each distinct vascular access site … CMS has become aware of new CPT guidance regarding the reporting of initial drug admin services in the event of a disruption in service; however, Medicare contractors are to continue to follow the guidance given in this manual. • For continuous services that last beyond midnight, use the date in which • the service began and report the total units of time provided continuously.

12. Challenges continued… • Additional examples of new text in the 2012 CPT book: • When reporting multiple infusions of the same drug/ substance on the same date of service, the initial code should be selected. The second and subsequent infusion(s) should be reported based on the individual time(s) of each additional infusion(s) of the same drug/substance using the appropriate add-on code. • Example: In the outpatient observation setting, a patient receives one-hour intravenous infusions of the same antibiotic every 8 hours on the same date of service through the same IV access. The hierarchy for facility reporting permits the reporting of 96365 for the first one-hour dose administered. Add-on 96366 would be reported twice (once for the second and third one-hour infusions of the same drug).

13. Challenges continued… • No one right solution to the charge capture question as it • depends on things such as: • Organizational culture/mentality • Volume and mix of services • Types of tools available • Budget issues • Use of “smart” electronic tools can result in “less memorization” of the CPT hierarchy and rules • Huge relief for nursing and coding staff alike • Results in lower compliance risk and fewer revenue leaks

14. Challenges Hospitals Face • Handling charge capture when patients are seen in different • clinics/multiple departments and receive a wide array or • combination of services • Should drug administration services be charge-driven at the • point of care or “coded” by HIM? • Nurse-driven charging at the point of care • HIM/coding on the back end from documentation • Combination of the above

15. Hierarchy Selecting Initial, Sequential and Concurrent (CPT) (AHIMA) • Chemotherapy infusions • Chemotherapy injections • Non-chemotherapy therapeutic infusions • Non-chemotherapy therapeutic injections • Other injections • Hydration

16. Exceptions for Initial Service Codes • More than one initial service code may be used when a patient has multiple encounters on the same day of service • More than one initial service code may be used when there are multiple lines in separate veins. • Modifier -59 will need to be applied to both

17. Initial, Sequential, and Concurrent, Drug Therapy • Initial is the first of a series of services • Sequential – are in a series or one after another (96367 – therapeutic or 96366 for additional hours of sequential infusion) • Concurrent – performed at the same time – usually through a separate lumen of the same catheter (96368)

18. Intravenous and Injection CPT Codes • 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour • 96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) • 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) • 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure) • 96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure) • 96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to one hour, including pump set-up and establishment of subcutaneous infusion site(s) • 96374 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug • 96375 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) • 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code

19. Definitions immersion of fluid through a vein or subcutaneously at a regulated rate, replacing or maintaining a fluid balance or adding medications or nutrients. (Hydration, IVPB) direct introduction of a drug or other fluid into the bloodstream or body tissue. (IVP, IM, Subq) Infusion Injection

20. Therapeutic Infusions96365-96366 • Initial or first hour of infusion is from 16 to 90 minutes (applies to therapeutic infusions; does not apply to hydration). • 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 (i.e., 91 minutes would allow an additional hour to be charged) • (Multiple infusions of different substances/drugs running through the same line may be separately reportable. Time documentation is critical since separate codes exist for initial, sequential, and concurrent infusions. Short duration is still defined as 15 minutes or less and this applies to chemo and non-chemo infusions (report using an IV push code) • These are time based codes – must have a start and stop time.

21. Therapeutic Infusion Times • Report the 1st hour infusion code (96365) when the infusion is greater than 15 minutes • Report additional infusion hours (96366) when more than 30 minutes have passed since the end of the previously billed hour. • Infusions that are = or< 15 minutes should be coded as an IVP (96374 /96375).

22. Therapeutic Injections 96374, 96375 and 96376 • CPT definition:“(a) 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” • 96374 – IVP – single or initial • 96375 – each additional IVP of a new substance/drug • 96376 – IVP injections of the same substance or drug • No separate APC attached • Must be over 30 minutes from last IVP of same med

23. IV Push Codes - IVP’s • Each IVP should have a separate time – pushes at the same time should be billed as one • IVP greater than 15 minutes is still a push - Drug pushed over 15 minutes, etc. is still a push (Ex: IV Ancef )

24. Hydration Coding 96360 and 96361 • What Are Hydration Infusions? • Defining “Medical Necessity” with Hydration Infusions • Hydrations 30 minutes or less, are not reported with a CPT. (e.g. Bolus) • Ensuring they are not a component of another procedure • Rate it is administered with a clear stop time. (clarifying KVO)

25. Hydration(96360-96361) • Report hydration (96360-96361) when the infusion is greater than 30 minutes • Report the subsequent infusion hour (96361) when documentation states that 31 minutes has passed since the end of the previously billed hour

26. Key Concepts on Hydration – CAHABA effective April 1, 2012 • IndicationsThe clinical manifestations of dehydration or volume depletion are related to the volume and rate of fluid loss, the nature of the fluid that is lost, and the responsiveness of the vasculature to volume reduction. Rehydration with fluids containing sodium as the principal solute preferentially expands the extracellular fluid volume; a 1-liter infusion of normal saline may expand blood volume by about 300 ml. In general, an imbalance of less than 500 ml of volume is not likely to require intravenous rehydration.

27. Indications continued…. • Hydration services are indicated: • In documented volume depletion. • When performed in conjunction with chemotherapy, these CPT codes are covered only when infusion is prolonged and done sequentially [done hour(s) before and/or after administration of chemotherapy], and when the volume status of a patient is compromised or will be compromised by side effects of chemotherapy or an illness. • In some endocrine conditions with findings such as hypercalcemia, prolonged hydration can be medically necessary. • As an adjunct to the treatment of hypotension

28. Hydration Limitations • Rehydration with the administration of an amount of fluid equal to or less than 500 ml is not reasonable and necessary. • These CPT codes are not to be used for routine IV drug injections. • Hanging of D5W or other fluid just prior to administration of chemotherapy is not hydration therapy and should not be billed with these codes. • When the sole purpose of fluid administration is to maintain patency of the access device, these infusion CPT codes should not be billed as hydration therapy. • Administration of fluid in the course of transfusions to maintain line patency or between units of blood product is not to be separately billed as hydration therapy. • Fluid used to administer drug(s) is incidental hydration and is not separately payable. • Rehydration via hydration therapy of extensively dehydrated patients can be accomplished in hours; therefore, the medical necessity of hydration beyond 12 hours must be documented in the medical record. • These CPT codes require the direct supervision of the physician or non-physician practitioner for the initiation of the service.

29. Hydration continued… Bill Type Codes: • Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. Revenue Codes: • Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

30. ICD 9 Codes that Support Hydration • The correct use of an ICD-9-CM code listed in the “ICD-9 Codes that Support Medical Necessity” section does not guarantee coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this LCD.ICD-9 codes must be coded to the highest level of specificity. Consult the ‘Official ICD-9-CM Guidelines for Coding and Reporting’ in the current ICD-9-CM book for correct coding guidelines. This LCD does not take precedence over the Correct Coding Initiative (CCI).

31. Supporting ICD 9 Codes • 250.80 • DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED • 275.42 • HYPERCALCEMIA • 276.0 • HYPEROSMOLALITY AND/OR HYPERNATREMIA • 276.50 • VOLUME DEPLETION, UNSPECIFIED • 276.51 • DEHYDRATION • 276.52 • HYPOVOLEMIA • 458.9 • HYPOTENSION UNSPECIFIED

32. Supporting ICD 9 Codes • 535.00 - 535.01 • ACUTE GASTRITIS (WITHOUT HEMORRHAGE) - ACUTE GASTRITIS WITH HEMORRHAGE • 535.10 - 535.11 • ATROPHIC GASTRITIS (WITHOUT HEMORRHAGE) - ATROPHIC GASTRITIS WITH HEMORRHAGE • 535.20 - 535.21 • GASTRIC MUCOSAL HYPERTROPHY (WITHOUT HEMORRHAGE) - GASTRIC MUCOSAL HYPERTROPHY WITH HEMORRHAGE • 535.30 - 535.31 • ALCOHOLIC GASTRITIS (WITHOUT HEMORRHAGE) - ALCOHOLIC GASTRITIS WITH HEMORRHAGE • 535.40 - 535.41 • OTHER SPECIFIED GASTRITIS (WITHOUT HEMORRHAGE) - OTHER SPECIFIED GASTRITIS WITH HEMORRHAGE • 535.50 - 535.51 • UNSPECIFIED GASTRITIS AND GASTRODUODENITIS (WITHOUT HEMORRHAGE) - UNSPECIFIED GASTRITIS AND GASTRODUODENITIS WITH HEMORRHAGE • 535.60 - 535.61 • DUODENITIS (WITHOUT HEMORRHAGE) - DUODENITIS WITH HEMORRHAGE • 535.70 - 535.71 • EOSINOPHILIC GASTRITIS, WITHOUT MENTION OF HEMORRHAGE - EOSINOPHILIC GASTRITIS, WITH HEMORRHAGE • 536.2 • PERSISTENT VOMITING • 558.9 • OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS • 578.0 • HEMATEMESIS • 585.3 • CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)

33. ICD 9 Codes continued… • 643.10 • HYPEREMESIS GRAVIDARUM WITH METABOLIC DISTURBANCE UNSPECIFIED AS TO EPISODE OF CARE • 643.13 • HYPEREMESIS GRAVIDARUM WITH METABOLIC DISTURBANCE ANTEPARTUM • 643.20 • LATE VOMITING OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE • 643.23 • LATE VOMITING OF PREGNANCY ANTEPARTUM • 643.80 • OTHER VOMITING COMPLICATING PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE • 643.83 • OTHER VOMITING COMPLICATING PREGNANCY ANTEPARTUM • 780.2 • SYNCOPE AND COLLAPSE • 780.4 • DIZZINESS AND GIDDINESS • 780.97 • ALTERED MENTAL STATUS • 787.01 • NAUSEA WITH VOMITING • 787.03 • VOMITING ALONE • 787.91 • DIARRHEA • V15.89 • OTHER SPECIFIED PERSONAL HISTORY PRESENTING HAZARDS TO HEALTH • V58.11 • ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY

34. Documentation Requirements • All 'Indications' must be clearly documented in the patient's medical record and made available to Medicare upon request. • The volume of hydration therapy and the doses of non-chemotherapy drugs administered should be documented in the medical record. • CPT Codes 96360 and 96361 are time-based codes and must be documented with start and stop times or total hydration infusion time. • Documentation must support CMS 'signature requirements' as described in the Medicare Program Integrity Manual (Pub. 100-08), Chapter 3.

35. Hydration Concepts continued… • When Not to code Hydration • When fluids are used solely to administer drug(s) or other substances or the administration of the fluid is incidental hydration and should not be coded, and not a component of another procedure • Keeping the line open (KVO or TKO) • When hydration if performed concurrent to another infusion • When specific time guidelines are not documented • Banana Bags – determined to be coded as IVPB’s. • When there is no stop time.

36. Drug Administration Integral to Other Services • If the drug administration service is typically performed pre- or post-procedure, then do not separately report. • Examples: Infusion of anesthetic for surgery; pre-op antibiotic injection/infusion; post-op pain and/or nausea injections; injections during CPR; injections for sedation analgesia • Coding Tip : Report pain & nausea IV pushes post-op using rev code 710 and no HCPCS to report the service and cost of providing patient-specific IV pushes • CCI edit manual makes clear that these are considered part of the operative procedure/service • 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 injection

37. Drug Administration Services Integral to Other Services Shifting definitions of “integral” is difficult for everyone. Transmittal A-01-13 issued November 20, 2001 Under OPPS packaged services are items and services that are considered to OPPS, be an integral part of another service that is paid under the OPPS… For example, routine supplies, anesthesia, recovery room and most drugs are considered to be an integral part of a surgical procedure so payment for these items is packaged into the APC payment for the surgical procedure. Transmittal A-02-129 issued January 3, 2003 Certain drugs are so integral to a treatment or procedure that the treatment or procedure could not be performed without them. 4th Quarter 2007AHA HCPCS Coding Clinic Although, the antibiotic infusion was specific to the patient and not part of the regular routine, the question remains whether or not the administration of the medication was due to the surgery. Therapeutic intravenous fluids, drug(s) or other substances administered that are integral to the procedure are not separately reported. Therefore, in this situation, the administration was prophylactic and would not be reported separately .

38. Modifier -59 Use • Separate IV/Vascular access sites • Separate visits or encounters during the same day • CCI Edits (seen in the encoder) - CT scans with contrast - CPT surgical procedures (including EKG’s) - Foley catheters Coding Tip: Just because an edit appears that would allow modifier -59, does not mean you should just add it and just because an edit doesn’t surface does not automatically mean that what you are reporting is allowed!

39. Issues in the Emergency Room • IV’s started in the field (hospital specific) • IV’s started for surgical procedures • -59 modifier issues • Hydration and Medical Necessity Issues • No key component information to support diagnostic conclusions and/or diagnostic/therapeutic plans

40. Issues In Observation Services • Will documentation support that the patient is receiving “active” treatment beyond usual post-operative care in order to determine whether the patient should be admitted as an observation patient or admitted as an inpatient? • Do you have an order to place in OBS? To admit to IP from OBS? • IV D/C’d is not a stop time for hydration or IVPB. • D/C’d on discharge? • Over one hour • Pre-set infusion times in MARS

41. Issues in Ambulatory/Same-Day Surgery • Unexpected circumstances or complications that are outside the normal scope of the procedure are billable under CMS – this must be supported by documentation. • Injections and Infusions that are an integral part of a surgical procedure or a normal protocol for that procedure should not be billed separately.

42. Documentation Red Flags • Extensive, repetitious unnecessary documentation –Unrelated to the presenting problem –“Blown in” records –Documentation by “exception” • CPT defined “work” not demonstrated –Procedures not documented –Level of effort not demonstrated • Circumstances described by modifiers are not demonstrated or documented in the chart

43. And Last but not Least….. • Remember… “If it’s not documented, it did not happen” . • “If it’s not documented, it should not be coded and billed” . • “If it’s not documented but it is billed and paid, problems will arise”. • Never Suggest the Following: Changing information after the fact (unsubstantiated back-end fixes) and changing information just to get the claim out the door and/or paid.

44. Resources: • HCPro, Inc. “Injections and Infusions – CPT Changes HcPRO, Inc. (May, 2012) • AMA – CPT, 2012 – Standard Edition • AHIMA“2011Procedure Code Updates,” Audio Seminar/Webinar (Dec, 2010) • “Getting a Line on Intravenous Therapy,” Coding Clinic (4th Q, 2001) • Medicare Coverage—Medical Necessity and Coding Basics – Debra Patterson, MD & Diana Adams, RHIA J-4 MAC Medical Trailblazer Health Enterprises (Oct, 2009) • Cahaba Government Benefit Administrators

45. Questions???