Health Information Management

Tip: What to look for when auditing injections and infusions

APCs Insider, April 23, 2010

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When you audit drug administration, begin by looking for proper documentation. Look for signed and dated orders. The orders are the start of your complete documentation record.

Ensure that staff members are documenting start and stop times. Time-based services come with a presumption that time is documented. Hospital documentation for infusion services that reflects the amount of the substance being infused and the flow rate is not sufficient.

Determine whether you adhere to the CPT coding hierarchy, as stated on p. 486 of the 2010 CPT Manual:

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.

Verify that the number of units coded and billed matches the number of units administered. Ensure that staff members code drugs according to their descriptions. Ensure that the units billed reflect the descriptions, which don’t necessarily match the manner in which manufacturers provide them.

This tip is adapted from “Audit injections and infusions to ensure correct coding” in the April issue of Briefings on APCs.



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