Drug Administration Uglies “Injections & Infusions Made Easy for 2014”

1. Drug Administration Uglies“Injections & Infusions Made Easy for 2014” Presented by Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc. “Finding HealthCare Solutions…Together” PO Box 2521Twin Falls, ID 83303(208) 423-9036 Daylee1@mindspring.com

2. Let’s Take a Closer Look • 2014 Drug Admin CPT codes and rules • Same ‘Renumbered’ CPT codes from 2009 • Review clinical scenarios related to some of these codes • Review documentation requirements and better practices • Time Documentation (start & stop) • Using Modifier -59 with Drug Administration Services

3. Who Are The New Cash Kings and Queens in the Outpatient Setting? • Nope, it isn’t pharmacy. Just revenue, not cash. • Nope, it isn’t supplies either. Just revenue, not cash. • Yes, it is Nursing! They are finally able to bill specifically for the services they provide in an outpatient setting. It’s about time!

4. Drug Administration Challenges For 2014 High area of lost revenue: ER to OBS, Direct admit to OBS, and OR to OBS. Co-mingling inpt and obs beds = highly problematic time charting for drug administration. Focus nursing on charting start and stop times to capture every minute. Charge capture is highly complex for nursing.

5. Attacking Problematic Charge Capture Processes Observation – IV Infusions, Injections, Blood Transfusions, Outpatient Procedures IDEA: Identify an owner to charge capture on the unit or move to Charge Capture Analyst. IDEA: Drug Administration & bedside procedures = major lost revenue. IDEA: Create Observation Attack Team to audit daily for billable time, G code, and charge capture for nursing procedures, Condition Code 44 = 1 touch.

6. 2014 Drug Administration “Uglies” Initial/primary reason for visit Use 9xxxx codes for all payers. C code/pump for Medicare only Once determined, initial/primary visit code (hydration, therapeutic, chemo)- then use subsequent CPTs for additional services All outpatient areas are impacted: ER, Observation, Hospital Based Clinics (HBC) IDEA: Nursing takes ownership for charting ‘stop and stop’ times per CPT IDEA: Create Charge Capture Analyst position

7. “Time” Charting Idea Create a stamp for Drug Adm start and stop times. (Could do recovery & 02 as they are timed charges) Use the stamp for billable time IV Hydration Infusion ______ _______ ______ _____ ______ (multiple lines) Start Stop Date Dept Initials IV Therapeutic Infusion _____ ________ _______ ______ ______ (multiple lines) Start Stop Date Dept Initials Remember! Time continues from the Emergency Room to the Observation/Outpatient areas

8. 2014 Drug Administration • No major changes in OPPS rules • Per-service APC payment continues • Financial impact related to drug administration services will vary based on your mix of services, hours of infusion, and internal charge capture practices • Majority of drug administration changes due to additional parenthetical notes

9. Drug Administration • Need to continue following CPT guidelines and instructions and MUST review CPT descriptors and parenthetical notes carefully! • From the hydration, therapeutic, prophylactic, and diagnostic injections & infusions section: • “Physician work related to hydration, injection, and infusion services predominantly involves affirmation of treatment plan and direct supervision of staff. These codes are not intended to be reported by the physician in the facility setting.” • Note: The above language was new in 2008… sets precedent regarding facility vs. physician reporting.

10. Drug Administration Changes? • Still the same! CPT has outlined a hierarchy from Nov 2005 CPT Assistant • Takes the guess work out of trying to figure out which drug admin service should be the “initial”, subsequent, etc. • “Initial” code should be selected using a hierarchy whereby: • Chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration services. • Infusions are primary to pushes, which are primary to injections.

11. Question: Does the fact that infusions are primary to pushes mean that hydration is primary to a push (IV push injection)? • Answer: No, because the first sub-bullet indicates that therapeutic, prophylactic and diagnostic services are primary to hydration services; an IV push is considered a therapeutic, prophylactic, or diagnostic service, therefore it is primary to hydration.

12. Clarification Please! • The CPT statement is: “The initial code should be selected using a hierarchy whereby chemotherapy SERVICES are primary to therapeutic, prophylactic, and diagnostic SERVICES, which are primary to hydration SERVICES. Infusions are primary to pushes, which are primary to injections.” • Within each “code set” have a further breakdown of the type of delivery/route/method (infusion, then the push, then the injection). • Since hydration is the last code set, and there is only one method (infusion), it would always be secondary to any other medication administrations.

13. Additional 2014 CPT Notes • When administering multiple infusions, injections or combinations, only 1 initial service code should be reported, unless protocol requires that 2 separate IV sites must be used and is medically necessary. • If a significant separately identifiable E&M service is performed, the appropriate E&M service code should be reported using modifier -25 in addition to 96360-96379. For same day E&M service a different diagnosis is not required.

14. More CPT Notes… Nothing New • If performed to facilitate the infusion or injection, the following services are included and are not separately billable: • Use of local anesthesia • IV start • Access to indwelling IV, subcutaneous catheter or port • Flush at conclusion of infusion • Standard tubing, syringes and supplies

15. IV Therapeutic Infusions & Injections • Codes all deleted and moved in front of the Chemotherapy CPT codes (renumbered) in 2009 – still the same for 2014 • Same 2014 CPT Codes: 96360 – 96379 • Same Heading: • Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration

16. Chemotherapy and Other Complex Drugs • Parenteral administration non-radionuclide anti-neoplastic • Anti-neoplastic for non-cancer diagnoses • i.e., Cyclophosphamide for auto-immune conditions • Monoclonal antibody agents • Other biologic response modifiers (BRM)

17. Why Included Here? • Very complex work and monitoring way beyond a ‘normal’ infusion • Possibility of severe reactions • Advanced practice training • Special consideration for prep, dosage, disposal • Frequent monitoring • Changes in infusion rate • Prolonged presence of nurse • Frequent communication with physician • If performed to facilitate infusion or injection, these are included and are not separately billable

18. Drug Administration Codes • CPT 96360: Intravenous infusion, hydration; initial, 31 minutes to 1 hour • Must reach 31 minutes in order to bill infusion • In 2007 we had 16 minutes (history tidbit) • Do not report hydration infusions of 30 minutes or less! No CPT code for this! • Hydration – IV infusion to consist of a pre-packaged fluid and electrolytes (i.e. normal saline, D5 ½ normal saline +30mEq KCL/liter), but are not used to report infusion of drugs or other substances. • “TKO” (to keep open) & “KVO” (keep vein open) cannot be charged.

19. Clinical Example # 1 ER patient presents with a laceration to the forehead

20. More CPT Codes for 2014 • CPT 96361: Intravenous infusion, hydration; each additional hour • List separately in addition to code for primary procedure) • Add-on code (+)

21. Still More… • CPT 96365: Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour • CPT 96366: Intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour • List separately in addition to code for primary procedure). • Add-on code (+)

22. CPT 96367: Intravenous infusion, for therapy, prophylaxis, or diagnosis; additionalsequential infusion, up to 1 hour • List separately in addition to code for primary procedure • Coding Tip! Do not report more than once per sequential infusion of the same mix.

23. CPT 96368: Intravenous infusion, for therapy, prophylaxis, or diagnosis; concurrent infusion • List separately in addition to code for primary procedure

24. And a Few More CPT Codes! • CPT 96369: Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s). • CMS Guidance: For infusions of 15 minutes or less, report with CPT code 96372 • Additional guidance: • Involves the placement of multiple subcutaneous accesses to infuse immune globulin • Includes an infusion pump to administer the infusion

25. CPT 96370 • CPT 96370: Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour • List separately in addition to code for primary procedure • Add-on code (+) = Must be reported with CPT code 96369 • For infusions greater than 30 minutes beyond one hour increments

26. CPT 96371: Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s). • Report with CPT code 96369 • Report 96371 only 1 time per day • CMS Guidance: “Captures the practice expense of obtaining additional accesses and the set up of a pump for infusions in larger individuals”.

27. CPT 96372: Therapeutic, prophylactic or diagnostic injection; subcutaneous orintramuscular (SC/SQ or IM) • Only CPT code that does NOT follow the CPT hierarchy – rules do not apply • Can report multiple SC/SQ/IM injections of the same substance/drug

28. More CPT Codes! • CPT 96373: Therapeutic, prophylactic or diagnostic injection, intra-arterial • CPT 96374: Therapeutic, prophylactic or diagnostic injection; IV push, single or initial drug

29. And Then There is CPT Code 96375… • CPT 96375: Therapeutic, prophylactic or diagnostic injection; each additional sequential IVP of a new substance/drug • List separately in addition to code for primary procedure • Add-on code (+) • 96374 + 96375

30. Confusion Still Exists! • CPT 96376: Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential IV push of the same substance/drug provided in a facility • Be careful! Code cannot be reported if a push of the same substance or drug occurred within 30 minutes (pushes of same substance or drug must be “31 “minutes apart) • Ex: Four hourly IVPs of Demerol would be reported as 96374 x 1 & 96376 x 3 as long as the time requirement is met Is the time documented in your medical record?

31. Using CPT 96376 Correctly • Report multiple individually prepared administrationsas individual drug administrations. • If the drug or substance is prepared one time and then administered in portions, report the administrations as only oneadministration (i.e. CPT 96374). • If the clinician administers a 2nd, separately prepared same drug in portions, this would equal a single admin of the same drug beyond a 30-minute interval (CPT 96376).

32. Now For The Bad News… • Medical record documentation by the clinician does not easily allow a coder to determine whether the IV pushes were individually prepared or administered in portions. • Still no separate APC payment assigned to this code for 2014.

33. Clinical Example # 2

34. Clinical Example # 3

35. Selecting Initial, Sequential & Concurrent CPT Codes • Initial • Code that best describes the key or primary reason for the visit • One code in each category of IV infusion and IV push drug administration codes has been designated as the “initial” service • Order of service delivery does NOT determine what is “initial” • Only one “initial” service should be reported per encounter UNLESS: • Protocol requires two separate IV sites • Multiple encounters are provided on the same DOS • Other drug administration services are also provided by a different route other than IV infusion or IV push

36. Question: How is the initial service selected? • Answer: The “initial”code that best describes the key or primary reasonfor the encounter should always be reported regardless of the order in which the infusions or injections were given. • This was not always clear in the past, but now the 2014 CPT book makes it explicit with a hierarchy! • Chemo infusions • Chemo injections • Non-chemo, therapeutic infusions • Non-chemo, therapeutic injections • Other injections • Hydration infusions

37. Sequential/Subsequent • Add-on codes (think “one after another” or “before or after the initial drug service”) • Should be used in addition to an “initial” code and the order of the services given does not matter • Reported once per encounter for the same infusate mix; additional hours reported with additional hours therapeutic infusion code (96366); and it is okay to report multiple sequential infusion codes if multiple different drugs are given • Infusion must be 16-91 minutes…apply the infusion time requirement

38. Question: How should an IV infusion of the same infusate that’s given multiple times during 1 visit be reported? • Answer: For example, calcium and magnesium are combined with D5W in an IV bag and one 20 minute infusion is given pre-chemo and one 20 minute infusion is given after chemo. This infusion would be billed as one sequential infusion, up to 1 hour (96367). The two 20-minute infusions of calcium/magnesium would be added together for a total of 40 minutes.

39. Concurrent (think “at the same time”) • Add-on code when multiple infusions are provided simultaneously through the same IV line, even with different bags. • No code for concurrent administration of chemo drugs, but if it does happen, then the unlisted chemo admin code 96549 should be reported. • Multiple substances mixed in one bag are considered to be one infusion, not a concurrent infusion. • There is no concurrent code for hydration. • Still no separate payment for the concurrent infusion code (96368) for 2014.

40. Concurrent Hydration with Separate Access Sites • If a separate venous access site is started for hydration along w/ another venous access site for a therapeutic infusion, report an “initial” code for the hydration and the appropriate “initial” code for the other infusion access site. • However, the CPT Manual makes it clear that hydration running concurrently through the same access site is still not separately reportable.

41. Selecting what the “initial” service is less of a mystery now! Yeah! • Fairly easy for scheduled clinic/infusion therapy and oncology patients. • Not as easy for unscheduled/ER visits so follow the hierarchy & read the CPT parenthetical notes. • Remember, hydration can be reported with other drug admin services, but it will typically not be reported with the “initial” service code. • Can’t always rely on an edit to tell if what you are charging/coding is correct or incorrect.

42. Key Concepts for Reporting • IV infusion of short duration is still defined as 15 minutes or less - report with an IV push injection code. • Initial or 1st hour of infusion is from 16 to 90 minutes (applies to therapeutic infusions but not to hydration). • Additional hours of infusion • Report add-on codes for additional hours of infusion (beyond the 1st 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).

43. Time Documentation • Per AMA– “Infusion time is measured when the infusate is actually running: pre and post time are not counted. It is recommended to document BOTH infusion start and stop times.” • Per CMS – “Hospitals are to report codes according to CPT instructions. Are to use the actual time over which the infusion is administered to the patient for time-specific drug administration codes.” • Remember that a reviewer must be able to determine the actual amount of time a medication infused from the records, not just the ‘ordered’ infusion time.

44. What If There Is “NO” Stop Time Documented? • Do you report an infusion, injection, or nothing when the stop time is missing? • CMS has stated that a short-duration infusion (i.e. less than 15 minutes) can be reported as an IV push injection……. therefore, if there is no stop time, would the infusion automatically be 15 minutes or less……since you don’t know if it was more? • CMS does not state anything about what can/cannot be reported if an explicit “stop” time is missing…..but several FIs have indicated that an IV push injection can be reported. • Remember, if there is no stop time for hydration you cannot report anything unless 30 minutes is charted.

45. Better Practice of Course… • Better practice is to require start and stop times for all drug administration services! • Regardless of how the charges are created, nursing's charting of start & stops does not change. • Financial impact of “down-coding” • CPT 96365 & 96366 CPT 96374 & 96375 • National APC payment • $129(1st hour infusion) vs.$36 (IV push) • Plus potential loss of any additional hour(s) @ $25 per hour Makes a huge difference to the bottom line!

46. Drug Admin Integral to Procedures • If the drug administration service is typically performed pre- or post-procedure, then you 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 • If the drug administration services is not typical for the procedure, then you do report it separately. • Examples: Anti-thrombolytic injection either pre- or post-surgery; anti-hypertensive injection

47. Hot Spots to Watch Out For! • ER to OBS • Handoff from ER to OBS – Do you maintain 2 separate nursing documentation tools? Are the drug administration services being captured correctly from the ER to OBS? • PP (Post-Procedure) to OBS • Cannot bill observation until 4-6 hours of routine recovery has passed • Direct Admit to OBS • Nursing needs to document all drug administration services as well as any bed-side procedures

48. Using Modifier -59 • Modifier -59 must be used in specific situations and you may find that you are using them more frequently than what was initially expected. • Use Modifier -59 if two vascular access sites are started • Use Modifier -59 if multiple encounters occur on the same date of service • CCI edits for drug admin are being applied in full, therefore the traditional rules for modifier -59 are in effect; no code pairs are exempt from the CCI edits

49. Using Modifier -59 • Most frequent CCI edit: When two initial service codes are paired together you will receive an edit message: • “Code 96365 is a component of code 96413 but a modifier is allowed in order to differentiate between the services provided.” • You can only have one“initial” service per IV site per encounter unless multiple lines are started. • Just because the edit appears does not mean you should add it just to get it out the door! • HIM department should be the ones to research WHY there was a rejection. NEED THE MEDICAL RECORD!

50. Dates of Service for Drug Admin What happens when the visit crosses the midnight hour? • On the January 2008 Open Door Forum call, CMS indicated that multiple “initial” service CPT codes should not be reported for a single encounter, even if the encounter crosses dates of service. • Do not “reset” the initial service CPT definitions just because the encounter has crossed the midnight hour. • Example: If a patient is in the ER on 4-10-13, and IV hydration is started @ 10:00pm and continues until 4-11-13 @ 2:00am, how would this look? • 96360 x 1 on 4-10-13 • 96361 x 1 on 4-10-13 • 96361 x 2 on 4-11-13