Health Information Management

Tip: Time documentation crucial for drug administration

APCs Insider, December 6, 2013

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Accurate time documentation is critical for drug administration coding because it can sometimes supersede the written language of an order.

For example, the physician may order an infusion, but if the administration lasts for less than 15 minutes, coders must report it as an IV push. However, an IV push that lasts for more than 15 minutes would not be reportable as an infusion since the CPT® Manual doesn't define or address a "long-duration" push and neither does CMS.

Noting the exact time is also important when reporting add-on codes for infusions. The initial service code is for up to one hour, but the add-on code for additional hours specify that the codes can only be reported if more than 30 minutes has elapsed since the end of the previously billed hour.

This tip is adapted from “Clearing the confusion with injections and infusions” in the December issue of Briefings on APCs.



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