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QA:Coding multiple initial infusions

APCs Weekly Monitor, April 17, 2009

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Q. A patient is to get IV antibiotics twice a day. Here is how I would bill this:

• 7 a.m.: 96365 (Initial intravenous infusion, up to one hour), quantity 1; 96366 (each additional hour) for any additional time during that episode.
• 7 p.m.: 96365, quantity 1; 96366 for any additional time during that episode

And so on; with, of course, the charge for the drug.

Other facilities are telling us that if a hep lock was placed during that 7 a.m. encounter, then you would not bill another initial for that day and that only one initial can be billed per day.

My argument is that when the CPT Manual states only one initial per day, they mean that you cannot bill an initial infusion and an initial hydration on the same day, and that the initial charge is based on the sequence of the infusion. But if the person comes in twice in one day, you take vitals both times and do the paperwork both times. This seems to make initial the valid choice for that second daily visit.

A. The answer depends on the actual scenario. In your specific example, it appears that the patient comes in at 7 a.m., receives his/her treatment and is discharged to return at 7 p.m. for a separate encounter. In this scenario, you will report an initial service each encounter, and append modifier -59 to the codes for the second encounter.

However, if the patient comes to the hospital for an outpatient service or observation services, the reporting is different. See the following, from the December 2007 CPT Assistant:

If patient is coming in for the listed scenario and crossing calendar days - i.e. OBSV [observation] services, same antibiotic given multiple times in same OBSV episode:

7:00 am 96365 x 1 with subsequent hour(s) [96366]
7:00 pm same calendar day - 96367 (sequential infusion; does not state SAME or DIFF drug) with [96366] subsequent hours
7:00 am next calendar day and patient continues to be observation- [96366] reported with hours
7:00 pm [96366] and so on. Report 96367 only once per sequential infusion of same infusate mix

In addition, see the note under CPT code 96367 in the 2009 CPT Manual:

Report 96367 in conjunction with 96365, 96374, 96409, 96413 if provided as a secondary or subsequent service after a different initial service is administered through the same IV access.

In the Medicare Claims Processing Manual, chapter 4, section 230.2, CMS notes the following:

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 one calendar day.

How you report your scenario depends on the documentation in the record and whether the patient presented for two separate encounters or a single, extended encounter.

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