Health Information Management

Catch up on what's new with injections and infusions

JustCoding News: Outpatient, May 2, 2012

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Poor documentation and a lack of clear guidance continue to cause coders to struggle with reporting injections and infusions.

CMS did not discuss drug administration services in the 2012 OPPS final rule, but the AMA did make significant additions to the CPT® coding guidelines in the 2012 CPT Manual, says Jugna Shah, MPH, president of Nimitt Consulting in Washington, D.C.

CPT changes to drug administrationguidelines
The 2012 CPT Manual now includes instructions stating that coders should report a significant, separately identifiable office or other outpatient E/M service along with drug administration services when appropriate. This is the first time the AMA has included such a guideline in the CPT Manual.

The guidelines instruct coders to report the appropriate E/M service (i.e., 99201-99215, 99241-99245, or 99354-99355) with modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) in addition to drug administration codes 96360-96549.

“The litmus test again is, is it significant and separately identifiable, and under audit, would you be able to demonstrate this from the medical record documentation?” Shah says.

The 2012 CPT Manual also includes more information on what a concurrent infusion is; a concurrent infusion occurs when a new substance or drug is infused at the same time as another substance or drug. This is not a time-based code per CPT, which can be confusing because we have been told that infusions as time-based services, yet in this case we are being told that a concurrent infusion is not to be viewed as time-based Shah says.

This means current infusions (CPT add-on code 96368) are only reported once per day regardless of whether the concurrent infusion lasts for multiple hours or if additional drugs or substances are administered concurrently.

Clarifying the guidelines
The 2012 CPT Manual also includes guideline changes pertaining to sequential infusions. According to the CPT guidelines:

All sequential services require that there be a new substance or drug, except that facilities may report a sequential intravenous push of the same drug using 96376.

Coders should hone in on the terms 'sequential’ and ‘new substance ot drug,’ Shah says. Those are two key parts of what sequential means when it comes to using the sequential infusion CPT code 96367.

In addition, providers should note that sequential itself just means coming one after the other and what is key is knowing if the item being infused is the same or different as that will guide code selection, Shah says. If the provider is not infusing a new substance, coders should not report the sequential infusion code, but instead should follow the CPT instruction which points to using the additional hours code to report additional infusions of the same substance or drug.

Many facilities have inquired about how to handle scenarios in which a patient receives an infusion of a drug and then receives a separate IV push of that same drug, Shah says.

For example, a patient receives a therapeutic infusion of a drug for one hour. Coders should report CPT code 96365 (intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour).

However, what happens when that same patient receives an IV push of the same drug? Coders know they should report an IV push code; however, they don’t always know which one is appropriate, Shah says. Many coders are confused about whether to report CPT code 96375 (therapeutic, prophylactic or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of a new substance/drug) or 96376 (therapeutic, prophylactic or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of the same substance/drug in a facility).

“What we know now is that we can use 96376,” Shah says, noting that coders may feel uncomfortable reporting 96376 without reporting an initial push code. However, the key to understanding the guideline is to remember that it’s the same drug—first as an IV infusion and then as an IV push. Coders may also feel uncomfortable about CPT’s clarification involving multiple infusions.

According to CPT guidelines:

When reporting multiple infusions of the same drug/ substance on the same date of service, the initial code should be selected. The second and subsequent infusion(s) should be reported based on the individual time(s) of each additional infusion(s) of the same drug/substance using the appropriate add-on code.

Coders should focus on the terms ‘multiple infusions,’ and ‘same drug or substance,’ Shah says. Coders already know to report subsequent infusions of a different substance or drug using the sequential infusion code. In cases where the same drug is being infused multiple times, coders must examine the time of each individual infusion and report it using the additional hours infusion code.

Remember, add-on codes for drug administration services don’t necessarily follow the standard way that coders normally think about using add-on codes which usually involves the main code before using the add-on code. That is not the case for drug administration services, Shah says.

The CPT Manual provides an example to illustrate how the guideline is applied: In the outpatient observation setting, a patient receives hour-long intravenous infusions of the same antibiotic every eight hours on the same date of service through the same IV access. Coders should report CPT code 96365 for the first one-hour dose administered. They should then report add-on code 96366 twice (i.e., once for the second hour-long infusion and once for the third hour-long infusion of the same drug).

It might look to coders like CPT is adding up the times of the three infusions of the same substance or drug but that is not what is happening; it just happens to work, Shah says. CPT guidelines state, ‘the second and subsequent infusion should be reported based on the individual times of each infusion.'

“So what they’re saying is if you've got the same drug and it’s infused multiple times, each infusion must be reported according to its own time. Moreover, if one of the infusions is longer, then it would be reported with 96366 and the additional time of it would also be reported using the same 96366 add-on code. Coders need to remember to report additional infusions of that same substance or drug using the add-on code, not the sequential infusion code and they need to remember that the add-on code now has multiple uses,” Shah says

CMS vs CPT guidelines
Coders know to follow CPT codes, rules, and parenthetical notes but what is difficult is when CPT provides one instruction and CMS provides another. In these cases, questions often arise about what instruction should be followed. For example, CPT provides one set of guidance on how drug administration services that cross the midnight hour should be reported while CMS provides another.

The difference here is that the CPT instruction is for physicians, while CMS’ instruction is for facility reporting and coders need to keep this straight.

CPT provides the following example: a patient receives intravenous hydration from 11 p.m. to 2 a.m. A coder reports 96360 once for the initial hour of hydration and 96361 twice for the additional hours.

The explanation for why this is the correct reporting according to CPT is because this is a continuous service. However, this is exactly the same reporting under CMS’ rules but the rationale is different. From CMS’ perspective this is the correct reporting because this is one single encounter in which case only one initial service code should be used unless two separate IV sites were accessed. The CPT guidelines go on to state:

However, if instead of a continuous infusion, a medication was given by intravenous push at 10 pm and 2 am., as the service was not continuous, both administrations would be reported with the initial service (96374).

“What we know from CMS is that this reporting instruction does not apply to hospitals because they are to report only one initial service per encounter regardless of whether services are continuous or not so in the above example, hospital reporting would dictate the use of 96374 and 96376. Hospitals should continue to follow Medicare Claims Processing Manual, section 230.2, Coding and Payment for Drug Administration, which states:

Drug administration services are to be reported with a line item date of service on the day they are provided. In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than 1 calendar day.

CMS notes in Transmittal 2386 that it has "subsequently become aware of new CPT guidance regarding the reporting of initial drug administration services in the event of a disruption in service; however, Medicare contractors are to continue to follow the guidance" in the Medicare Claims Processing Manual, Chapter 4, section 230.2.

Medicare is clearly aware of the CPT instruction, but is making it clear that hospital reporting must be done differently, Shah says. “It [Medicare] is going to continue following the rules that it has had in place now for drug administration where you have one initial service except in very specific instances, such as multiple vascular access sites or multiple separate visits.

In this example, coders would not follow the CPT instruction but instead would continue to follow CMS guidance. CMS states that for continuous services that extend beyond the midnight hour, such as hydration, hospitals should use the date on which the services begin and report the total units of time during which the services are provided continuously using the appropriate codes and time frames without being tempted to use another initial service code simply because the midnight hour was crossed. Don’t be confused by the example in the CPT Manual about the IV push, Shah says.

Coders may resist Medicare guidance because they generally adhere to CPT standards when coding, says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc., in Danvers, Mass. They may argue that they don't code according to payer policy; however, in some instances, they must, she says. "If they don't code to Medicare's policy, they may have overpayments that could be considered fraud."

Because Medicare is such a large governmental payer, it establishes some of its own rules, Hoy says. This allows CMS to set rules that are technically contrary to HIPAA standards.

Other payers may also default to the Medicare rules, so someone within the organization must identify the guidance that each third-party payer is following. "If you have it figured out for Medicare, and you know a limited number of your payers are using the Medicare rule, just follow the Medicare rule for them," Hoy says. "For everyone else, standard coding rules should be applied."

Organizations must also familiarize themselves with the rules that their individual MACs follow, Hoy says. Many of the differences between Medicare policy and CPT guidelines reside in local MAC guidance about how to document or use the codes. Although some national standards exist, CMS often defers to the MACs. Thus, not all MACs follow the same rules. Fortunately, most organizations must only learn the rules of one MAC.

HIM staff members should ensure that coding rules are reflected in the facility's coding software, Hoy says. This will help the facility track each of the different rules.

Editor’s note: This article was originally published in the April issue ofBriefings on APCs. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at

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