Health Information Management

Tip: Selecting codes and counting time for injections and infusions

APCs Insider, March 25, 2011

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Coders still follow the hierarchy when selecting codes, and the AMA added only one new code for 2011. However, common questions about correct coding persist. Before selecting a code, coders must determine:

• Substance being infused
• IV site
• Flow rate
• Start and stop times

Drug administration services use time-based codes. Therefore, best practice requires that documentation reflect time to support these time-based codes.
Individuals who charge or code for drug administration services (e.g., nurses at the point of care or coders in HIM) must remember the reporting requirements for services related to time. For example, an infusion that lasts for 15 minutes or less must be reported as an IV push injection.

According to the AMA, infusion time is measured when the infusate is actually running, This means that pre- and post-times associated with services such as the patient being prepped or monitored or occupying a treatment room may not be used to calculate overall infusion time.

The tip is adapted from “Resolve continuing questions about injection and infusion coding” in the March issue of Briefings on APCs.

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