Health Information Management

Guiding principals help ease the sting of injection and infusion coding

JustCoding News: Outpatient, April 7, 2010

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When the topic of coding for injections and infusions comes up, it’s difficult to steer the conversation in one direction. There are simply too many variables, rules, and definitions to take into consideration, making it nearly impossible to have any single rule of thumb when coding for these services.

Coders who juggle facility coding and professional coding had historically reported CPT codes by the hour and HCPCS Level II codes per session. But in 2005, injection and infusion codes got a makeover and HCPCS Level II codes were aligned with the CPT code definitions.

And when this change occurred, it happened rather quickly. CMS issued guidance in December 2005 for codes that would take effect January 1, 2006. This put coders in the difficult position of having to absorb and adjust to the new guidance in a short period of time.

“You can’t imagine how many chargemasters had to change,” says Maria Shinn Bouck, CPC, healthcare consultant at Cohen & Company in Westlake, OH.

Today, injection and infusion coders must still take into account so many variables that the coding is difficult to keep it all straight. And the icing on the cake—guidelines for physician coding are different from those for hospital coding.

Luckily, there is guidance that can help coders make their way through the maze of possibilities and arrive at the correct injection and infusion codes.

Master the documentation basics
The codes for injections and infusions are time-driven, which in itself presents a challenge because documentation of start and stop times is often incomplete. To complicate matters, the time requirements change depending on whether the claim involves hydration versus another type of therapeutic infusion therapy, says Christi Sarasin, CCS, CPC-H, CCDS, FCS, and CEO of Sarasin Consulting Group in Friendship, MD.

Providers need to document the following for coders to determine the appropriate codes:

  • Physician order
  • Site(s)
  • Drug(s)
  • Method (e.g., bolus, port, pump)
  • Start time
  • Stop time
  • Rate of infusion

Providers frequently neglect to document stop times, particularly in the ED. When a patient’s drugs are still running when he or she is transferred to the floor, the ED provider has no idea what time to stop charging the hours, Bouck says. It’s also quite common for providers to forget to note stop times for patients who have multiple drugs running.

“Nurses have to know when they expect the drugs to stop infusing so they can note the stop times. But many times the drug has either stopped infusing or the line has infiltrated, meaning the IV came out of the vein, and no stop time has been documented,” Bouck says.

Some providers use standard forms to try to capture all the necessary details to code accurately. However, some forms don’t go into enough detail as far as breaking out different elements. For example, even when the provider documents the initial site, start time, drugs, and stop time, if there’s no additional detail to clarify whether an additional infusion is subsequent or concurrent, coders won’t be able to assign the appropriate codes, Sarasin says. Click here to access five coding examples.

“I think facilities are probably giving these services away,” she adds.

Find out which drugs qualify for chemotherapy administration code
Coders often mistakenly report a therapeutic injection or infusion administration when they should report the administration code for chemotherapeutic drugs, Sarasin says.

Bouck agrees, adding, “Hospitals leave that money on the table every time.”

Coders need to understand that CMS classifies some nonchemotherapy drugs in the same group for which they would report a chemotherapeutic drug administration code because of the complexity and the higher risk and skill level associated with administering them, Sarasin says.

This means that coders have to keep up-to-date on drug classifications, which is also challenging because of the nature of the changing landscape of approved drugs.

Bouck suggests that in hospital settings, coding managers should meet quarterly with the pharmacy director to get a formulary and a list of drugs that qualify as complex/chemotherapy infusion drugs (e.g., Remicade®).

The CPT Manual states:

Chemotherapy administration codes 96401–96549 apply to parenteral administration of non-radionuclide, anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers. 

“Then the coding manager needs to educate coders about which drugs qualify and which drugs should trigger the chemotherapy administration code,” Bouck says. Taking into account just the first hour of infusion, this could mean the difference between a facility payment of $127 for the first hour of a regular drug administration versus a payment of $220 for the first hour of a chemotherapy drug administration.

Report only one initial service code
Bearing in mind the hierarchy of reporting injections and infusions, coders need remember to report only one initial service.

For example, a therapeutic infusion of a nonchemotherapy drug may be running for four hours. Then after that fourth hour, the provider administers a chemotherapy drug. Report the initial therapeutic infusion with a code for each additional hour instead of an initial service code, Sarasin says. Due to the complexity and risk of the chemotherapy drug, the hierarchy guidelines in the CPT Manual establish that you should report that as your initial service code, she says.

“This can be confusing because you’ve been running a therapeutic infusion, but the code we’ll identify as the initial is for the drug given four hours later,” she explains.

When coding multiple injections and infusions, coders need to understand the definition of an initial service to help them determine which code to report. Always follow the hierarchy regardless of the purpose of the patient’s visit, Bouck says.

“When these codes are reported by the physician, the ‘initial’ code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur,” according to CPT Assistant, February 2009, pp. 17–21.

However, this same CPT Assistant also provides the following guidance for facility reporting:

When these codes are reported by the facility, the following instructions apply:

  • 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.
  • The hierarchy is always followed, regardless of the apparent purpose of the visit.

Understand the difference between hydration versus infusions
A hydration is a premixed bag of electrolytes. However if the nurse adds a drug, this case now counts as a therapeutic infusion, and coders need to recognize there are different time requirements for hydration versus therapeutic infusions.

When therapeutic infusions are 15 minutes or less, code an IV push. Anything longer than 15 minutes, and you can code an infusion up to that first hour, Sarasin says.

However, hydration services must extend longer than 30 minutes to be able to code that first hour, she adds.

Also consider access versus actual administration when evaluating time requirements.

Even though a provider may have placed an IV at 10 a.m., he or she may not have started the actual administration of a drug until 12 p.m. The units reported need to reflect the time the provider infused the drug, not just the presence of the IV in the patient, Sarasin explains.

Use modifier -59 sparingly
Take note that a patient may have multiple injection and infusion sites (e.g., left arm and right arm, right arm and port); it may be necessary to access multiple sites when two drugs can’t run together, Sarasin says. When it’s medically necessary to do so, assign a second initial service code and append modifier -59 (Distinct procedural service) when reporting the services. Keep in mind, however, that reporting modifier -59 to indicate multiple initial services should be a relatively rare occurrence.

Editor’s note: E-mail questions to Managing Editor Doreen Bentley at

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