Health Information Management

An explanation for drug administration CPT codes 'hierarchy'

APCs Insider, March 2, 2007

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An explanation for drug administration CPT codes 'hierarchy'

Note: APCs Weekly Monitor received a number of questions since its January 26, 2007 publication of the "hierarchy" of the 2007 CPT drug administration codes (i.e., the order/combination in which you should report these services), which included the following order of services:

  • Chemo infusions
  • Chemo injections
  • Non-chemo, therapeutic infusions
  • Non-chemo, therapeutic injections
  • Hydration infusions

Following is some additional clarification on why this "unofficial" hierarchy is useful.

The hierarchy presented in the APCs Weekly Monitor was developed by close and careful reading of the language and parenthetical notes provided in the CPT Manual for hydration; therapeutic, prophylactic, diagnostic, and chemotherapy infusions and injections; as well as guidance in CPT Assistant, and the AHA Coding Clinic for HCPCS, volume 3 (in fact, CPT Assistant actually uses the term "hierarchy"). While not explicitly stated in the official guidance, the drug administration hierarchy listed above is one of the few ways to sort through what combinations of codes you can report together-particularly in the absence of more explicit guidance from CPT, says Jugna Shah, MPH, president of Nimitt Consulting in Washington, D.C.

Currently, CPT instructs providers to select the initial service drug administration code based on the primary reason for the encounter. However, this can prove problematic. Here's an example why: A patient arrives in the ED and staff start an IV infusion for hydration. Two hours later, staff administer an IV push pain injection.

To report these services, a coder/nurse at the point of care charges 90760 as the initial service (hydration infusion) since it was the first service provided, and then 90775 (IV push pain injection). The coder selects 90775, and not 90774, since he or she can only report one initial service code.

Although this is an intuitive way to report these services, the parenthetical note in the CPT Manual does not include 90760 as one of the codes that you can report with 90775. This scenario demonstrates why you should report the IV push injection using an initial service code, even though it was the second service provided and perhaps not the primary reason for the ED visit. Therefore, the correct codes for the above scenario are 90774 and 90761--not 90760 and 90775.

This scenario raises a question of how to reconcile the apparent primary reason for the visit versus what services you can report in combination with each other. "What we know is that the parenthetical notes in the CPT Manual seem to provide the best coding guidance about which code combinations can be reported together," says Shah. "Since the notes provide guidance about what codes can be reported with other codes, I believe this information can and should be used to develop some natural hierarchies."

Reading through these notes reveals codes that you must report as initial over other services, regardless of the order in which the services are provided. CPT also indicates that the initial service is not necessarily the first service provided.

Note that you are not likely to trigger CCI edits when you report certain code combinations together. For example, reporting 90775 and 90760 together will not generate an edit. But this does not justify reporting codes in a manner that violates the parenthetical notes in the CPT Manual.

Finally, the November 2005 CPT Assistant, Volume 15, established a hierarchy/theory for when you report IV infusions with an IV push during the same encounter. CPT Assistant refers to this as a primary and secondary hierarchy. While it does not contain the same explicit hierarchy provided in the APC Weekly Monitor, this language is consistent with the thought of reporting these codes in a natural hierarchy, if only to help train staff, develop encounter forms, charge tickets, etc.

We hope you find this explanation helpful.

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