Health Information Management

Injections and infusions continue to confuse coders

JustCoding News: Outpatient, June 13, 2012

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Consider this scenario: A physician orders three hours of hydration as well as a one-hour therapeutic antibiotic infusion for a patient. A nurse documents the hydration start time as 10 a.m. and the antibiotic start time as 11 a.m. Neither provider documents a stop time. What should coders report?

Without stop times, coders can’t report much. An absence of start and stop times is one of the more frequent challenges that coders face when reporting injections and infusions, says Denise Williams, RN, CPC-H, vice president of revenue integrity services for Health Revenue Assurance Associates, Inc., in Plantation, Fla.

“Because CPT® guidelines define infusions based on the amount of time involved, without specific time frame documentation for infusions, it is difficult to determine whether to report the infusion as an infusion or an IV push,” Williams says.

If a provider documents giving a drug as an IV, the provider must also specify whether it is a push or document the start and stop time frame. Otherwise, the coder has no clear documentation regarding the administration.

Coders can’t code from the physician order alone—they must also verify whether the service was performed at all, and if so, whether it was performed in its entirety, says Jugna Shah, MPH, president of Nimitt Consulting in Washington, D.C. This means that without documentation of stop times, coders can’t assume the infusions took place or that they ran for a certain length of time.

In the scenario above, even though the physician ordered three hours of hydration and a one-hour therapeutic infusion, coders can’t code the services at all because no stop time is documented.

Review the hierarchy
CPT guidelines include a hierarchy for coding injections and infusions. If coders aren’t familiar with it or don’t follow it, they can inadvertently end up either overcoding or undercoding the services, says Shah.

“What we find most often in situations where someone is struggling with reporting these services is that they don’t have a solid understanding of the hierarchy and may not be aware of their FI/MAC’s specific instructions on reporting drug administration services,” Williams says.

Chemotherapy services are primary and should be selected as initial when provided in conjunction with therapeutic, prophylactic, or diagnostic services, says Shah. Remember, the hierarchy applies to all IV injection and infusion services. In most cases, all of these services would be selected as the initial service before hydration if hydration is provided during the same encounter as another IV injection or infusion service (with the exception of two separate IV sites). Coders also need to remember that the order of the service delivery does not determine what’s initial. Even if a patient receives hydration first, followed by a therapeutic infusion, and then finally chemotherapy, the chemotherapy would be reported as the initial service according to the hierarchy.

“If you refer back to the hierarchy,” Shah says, “you’ll never go wrong and will see why it’s okay to report a service that was given last in the day as the initial service compared to the first thing that was done in that visit.”

The hierarchy does not apply to physician reporting, nor does it apply to subcutaneous or intramuscular injections, Shah says.

Select the initial service
Typically, coders will report only one initial service per visit, unless the patient has more than one access site, Shah says. So if a patient receives hydration with IV pushes, with therapeutic infusions, or with chemotherapy, hydration can be reported but not as an initial service unless a separate IV line was started for it. Also remember that hydration that occurs concurrently with another infusion service cannot be reported per CPT rules. Typically hydration is only reported as an initial service when it’s provided with no other drug administration services, or when it’s provided with non-intravenous injection and infusion drug administration services.

Each category of IV infusion and injection codes designates one code as the initial service.
Coders should remember that the order of the service delivery doesn’t determine what’s considered the initial vs. subsequent services. If a patient receives hydration and then a therapeutic infusion followed by chemotherapy, coders should always report the chemotherapy first, Shah says.

Typically, coders report only one initial service per visit, unless the patient has more than one access site, Shah adds.

Code subsequent and sequential infusions
The codes for subsequent and sequential infusions are add-on codes. Think of these infusions as one after ¬another or an infusion that comes before or after the initial drug, Shah suggests.

Sequential infusions denote the administration of a new drug or substance. Coders can report these codes once per encounter for the same infusate, Shah says.

Coders can report sequential infusion codes for additional different drugs that are given. But if the same drug is given multiple times, then use 96366, the additional hours code associated with the sequential therapeutic infusion. The additional hours code 96366 is now used to report multiple services, including the following:

  • Additional hours of the initial service infusion
  • Additional hours of a sequential infusion, which means additional hours of an infusion of a new drug
  • Additional infusions of the same substance or drug

Coders can report 96366 (intravenous infusion, therapy, prophylaxis, or diagnosis; each additional hour) for additional hours of the initial infusion. For a sequential infusion of a new drug, coders should report 96367 (intravenous infusion, therapy, prophylaxis, or diagnosis; additional sequential infusion, [list separately in addition to code for primary procedure] up to one hour).

Consider this scenario: A patient receives antibiotic A for three hours. Coders should report a code for the initial hour, followed by 96366x2 for the remaining additional two hours, Shah says.
However, a different patient might receive two different drugs (antibiotic A and antibiotic B) during the same visit. In this case, coders should report the initial infusion for antibiotic A with 96365 and use 96366 for any additional hours of that infusion.

For antibiotic B, coders would use 96367, and if this second infusion ran for two hours, then the additional hours of this sequential infusion would be picked up with 96366 as well. But if the physician ordered three separate one-hour infusions of antibiotic A, and the provider gave and documented them with separate start and stop times, then 96365 would be used to report the first and 96366 for the second and third infusions of the same drug.

Coders can report codes that include subsequent/sequential in their descriptions even if those codes are the first service in a group of services (e.g., first IV push subsequent to an initial one-hour infusion reported using the subsequent IV push code), Shah says.

“This is where we were saying the order doesn’t matter. You have to follow the hierarchy,” she says.

Report concurrent infusions
Unlike subsequent infusions that run after an initial infusion, concurrent infusions run at the same time as another infusion. Codes for concurrent infusions are add-on codes that denote multiple infusions running simultaneously through the same line, Shah says.

CPT doesn’t include a code for concurrent administration of chemotherapy. If a patient receives concurrent chemotherapy infusions, coders should report the unlisted chemotherapy administration code 96549.

Substances mixed together in one bag are considered one infusion—not concurrent, Shah says. In addition, CPT doesn’t include concurrent codes for hydration, and facilities don’t receive separate payment for concurrent hydration.

Coders can assign the concurrent code when a patient receives chemotherapy and a therapeutic infusion simultaneously into the same line. They can also report it when the patient is receiving two different non-chemotherapy drugs, Shah says.

Decide what to code
Coders can create a decision tree to help them determine what services to code and the order in which to report those services.

Start by determining whether the patient received any chemotherapy infusions during the visit. If yes, code the chemotherapy first.

Second, look at the route of administration. Is it IV infusion, IV injection, subcutaneous/intramuscular, or a combination? This is important because it also drives selection of codes, Shah says.

Next, determine the duration of each infusion. Was it fewer than 15 minutes, more than 15 minutes, one hour, or more than one hour? Time is critical for being able to code infusion services correctly, Shah says. “How can we ever get to additional hours if we don’t know how long the service took? So this is very important in terms of time and time documentation.”

Improve injection and infusion coding
Coders should reread the instructions in the CPT Manual each year, Williams says. Although CPT did not change the codes for injection and infusion services in 2012, it did significantly revise some of the guidelines.

The most significant changes occur in the instructions and parenthetical notes associated with the codes. CPT added new language regarding 96366 (intravenous infusion, for therapy, prophylaxis or diagnosis; each additional hour), which instructs coders to use this code for “each second and subsequent infusions of the same drug/substance.”

“The positive part of this is that it works in ¬tandem with the updated definition for CPT code 96367, which now specifies sequential infusion of a new drug,” ¬Williams says.

The introductory instructions also better define how to report a scenario in which a drug is given as a push injection and also as an infusion. The instructions now specifically state that both can be reported.
Coders should report the infusion with the appropriate time-based code (infusion vs. push) and CPT code 96376 for the IV push (subsequent push of the same drug). “There were many iterations and opinions on how this should be reported in the past, so to have specific instructions is helpful,” Williams says.

In addition, coders should read the OPPS update transmittals to determine whether CMS has changed any guidance. It is always a good idea to revisit this subject with everyone involved in providing/documenting the services so they understand what has changed, Williams says. “Knowledge and understanding is the key to documenting, coding, billing, and reporting services correctly to ensure and maintain revenue integrity.”

Improving the documentation of start and stop times should not be an adversarial process, Williams says. Opening the lines of communication across departments ensures that everyone understands why accurate and complete documentation is a necessity.

“It is about complete and accurate documentation to reflect the details of the services provided,” says Williams. “Complete and accurate documentation also has a quality of care impact that sometimes gets lost in the ‘document it so I can bill it’ discussion.”

Editor’s note: This article was originally published in the June issue of Briefings on APCs. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.



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