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Report code 90765 for first hour, code 90766 for additional hours of IV infusion

APCs Weekly Monitor, February 15, 2008

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QUESTION: We have a designated observation unit where we treat patients with IV infusion (i.e., therapeutic drugs) overnight. How should we report an infusion of therapeutic medication that starts at 11 p.m. and ends the next day at 11 a.m.? Does the daily initial service rule apply in this scenario?

ANSWER: Report CPT codes for infusions based on hours per encounter, not per day. The CPT Manual states that you should report only one "initial" service code per encounter, unless the physician establishes more than one vascular access site. Report one "initial" service code per vascular access site, per encounter.

In the scenario above, a therapeutic infusion ran for 12 hours over two calendar dates during one encounter/visit, and the initial service began on the date of admission.

In this case, report the admission date as the date of service for the initial service. For example, if the patient was admitted on February 1, note this as the date of service for CPT code 90765 (IV infusion, for therapy/prophylaxis or diagnosis, up to one hour), and report 11 units of code 90766 (each additional hour) for the remaining infusion time. The Medicare Outpatient Code Editor will accept the date of service for code 90766 (February 2) as the actual date of service. Other payers may have edits that require you to report add-on code 90766 with the same date of service as the initial code meaning both 90765 and 90766 would be billed with February 1. Either method is acceptable and allowable, so determine what works best across all your payers.

If the patient was scheduled for an infusion, ensure that you do not bill observation hours because payment under the OPPS includes the time allocated for the patient to be in a hospital bed. If all other observation criteria are met, observation hours are billable only when the patient had a separate condition that the physician evaluated and/or treated.

Note: Correction
In last week's Q&A, we incorrectly described status indicator "N" as representative of a non-covered service that Medicare will not pay for. However, status indicator "N" indicates that payment for a particular service is bundled into another APC, so there is no separate payment. The remainder of the answer is correct. We apologize for the confusion.

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