Health Information Management

Tip: Correctly select initial infusion service

APCs Insider, July 6, 2012

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Typically, coders will only report one initial service per visit, unless the patient has more than one access site. 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.
 
Typically, coders only report one initial service per visit, unless the patient has more than one access site.
 
The tip is adapted from “Injections and infusions continue to confuse coders” in the June Briefings on APCs.



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