Health Information Management

Audit injections and infusions to ensure correct coding

JustCoding News: Outpatient, May 5, 2010

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In an environment of increasing audits, hospitals must monitor and resolve drug administration coding, billing, and charge capture problems. One way to do that is to audit this area to highlight revenue opportunities and compliance risks, says Valerie Rinkle, MPA, revenue cycle director at Asante Health System in Medford, OR.

“If there is one area that I really encourage you to spend a lot of your auditing and monitoring time on, it is in drug administration,” Rinkle says. Drug administration includes several significant concepts, and all of those concepts drive back to documentation for medical necessity and time, she says.

Units of service for hydration is already a Recovery Audit Contractor target, and this is just the beginning, warns Jugna Shah, MPH, president of Nimitt Consulting, Inc., in Washington, DC, who expects to see an increasing number of audits focused on drug administration. Being educated, prepared, and knowledgeable about the rules is critical. “If you get a consultant or auditor telling you something that is different from what you know the rules to be, please challenge that,” says Shah.

Who’s on the auditing team
The team auditing your drug administration charges should include coding and billing staff involved in charging for drug administration service and compliance.

Make sure you also have support from the top, Shah says, adding that outside consultants can be helpful in guiding or conducting your audit but may not be necessary if you are already tracking drug administration completeness and accuracy internally.

What to audit
When you audit drug administration, start by looking for proper documentation. Look for signed and dated orders. The orders are the start of your complete documentation record. “You’ve got to have clear orders,” Shah says. “Without orders, there’s no point in talking about anything else that was charged.”

Make sure staff members are documenting start and stop times. “Time-based services come with a presumption that time is documented,” Shah says. Hospital documentation for infusion services that reflects the amount of the substance being infused and the flow rate is not enough, she says.

Check to see whether you are following 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.

“You can’t just rely on the presence or absence of edits,” Shah says.

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. Make sure the units billed reflect the descriptions, which do not necessarily match how manufacturers provide them.

In addition, use modifier -59 (distinct procedural service) only when appropriate. Modifier -59 must be used in specific situations, but providers may find themselves using it more frequently than typically expected. Just because an edit appears that would allow modifier -59 does not mean you should add it. “You want to make sure you have looked at the appropriate application of that modifier,” Shah says.

When to conduct monitoring
Consider conducting charge reconciliation daily, says Rinkle. If you don’t have a process for charge reconciliation, she recommends starting one.

Think about performing monthly audits. Conduct an internal audit by selecting 20 records and pulling the detailed bill, the UB-04, and the remittance. Then audit for accurate and complete reporting and payment, Rinkle says.

Test your staff members by presenting clinical scenarios for them to code. You can give the same scenario to all of the staff members who capture drug administration charges. That will help you ensure that all of your coders are coding the charges consistently, and it will also highlight areas where you need to educate your staff. At the very least, you should be doing this annually, Rinkle says. “So much revenue is associated with drug administration that it’s another important reason just to make sure you are not losing revenue,” she explains.

Which cases to audit
Look at cases in which you have a large number of units, Rinkle says. The Office of Inspector General has conducted audits focusing on units of service, and other payers have conducted audits across the country focusing on units of service greater than the typical number.

In addition, review cases with concurrent and sequential drug administration. Make sure your units are correct and all of the documentation is accurate, present, and supports the medical necessity of the service, Rinkle says.

Trend any denials and look at your edits. If possible, determine where your most frequent National Correct Coding Initiative or medically unlikely edits are occurring. “Select an audit of those to make sure your application of modifier -59 is appropriate,” Rinkle says.

Use clinical examples to test coding accuracy
One way to ensure that all of your staff members who capture drug administration charges are doing so accurately is to test them. Provide staff members with clinical examples similar to the one the following, which Shah provided.

A patient receives an IV push of Demerol, later an IV push of morphine, and then an IV push of Demerol with Phenergan (mixed together and given in one syringe).

How to code
It’s clear that the patient received three pushes of at least two substances—Demerol and morphine. But what is less clear is whether Demerol and Phenergan, two separate substances that were mixed together and administered in one syringe, would be considered a new drug/substance, Shah says. Is the mixture considered a different substance from the Demerol administered earlier? The answer in this case is yes, she says.

In this scenario, you would code:

  • 96374 (therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; intravenous push, single or initial substance/drug), for the IV push of Demerol
  • 96375 (therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of a new substance/drug [list separately in addition to code for primary procedure]), for the IV push of morphine
  • 96375, again, for the IV push of the Demerol and Phenergan mixture

You would report code 96375 twice because the provider administered two substances after the initial IV push, Shah says.

Editor's note: This article was originally published in the April issue of Briefings on APCs. E-mail your questions to Managing Editor Michelle Leppert at

For more clinical scenarios and information about coding for injections and infusions, order a recording of HCPro’s January 19 audio conference “Injection and Infusion Billing and Coding: A Roundup of the Current Rules, Trouble Spots, and Audit Tips.

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