1. Injection and Infusion Coding
Presented by:
Dawne Beckley, RHIA, CPC
National Compliance Manager
himagine solutions

2. About the Speaker
Dawne Beckley, RHIA, CPC is a National Compliance Manager at himagine solutions with over 20 years experience in health care and HIM Coding, auditing, and reimbursement. She specializes in the areas of Outpatient Coding Compliance, APC and CDM reviews, physician coding reviews, education, and support for Health Information Management professionals.

3. Disclaimer
himagine solutions has prepared this program using official Centers for Medicare and Medicaid Services (CMS) documents, Federal Register and recognized input from the Cooperating Parties. Every reasonable effort has been made to ensure the program’s accuracy. Never-the-less, the ultimate responsibility for correct use of the coding system lies with the user.
himagine solutions, its employees, and staff make no representation, warranty, or guarantee that this information is error-free, or that the use of this program will prevent differences of opinion with payers. The company will bear no responsibility or liability for the results or consequences of the use of this program. The program is presented “as is” without warranty.

4. Are You Ready? Or do you look like this?

5. Objectives Overview of services
Review coding guidelines for injection, infusion and hydration
Documentation requirements
Case scenarios
Questions

6. Determining the Hierarchy
Tier 1 – Type of Service
Chemotherapy
Therapeutic/prophylactic/diagnostic
Hydration
Tier 2 – Administration Route
Infusions (Therapeutic)
IV Pushes
Injections (SQ and IM)

7. Determining the Hierarchy
There are different determinations for physician services versus facility services.
Infusions are primary to pushes, which are primary to injections.
The hierarchy is to be followed by facilities as well as parenthetical instructions for add-on codes or additional reporting.
Physician (Professional) coding focuses on the primary reason for encounter- not the hierarchy.

8. Determining the Hierarchy
Example –
Patient presents to the ED with nausea and vomiting. Patient receives normal saline from 8:00 am to 11:00 am. Also received an IV push injection of Zofran at 10:30 am.
What service will be reported first?

9. Determining the Hierarchy
Example –
Patient presents to the ED with vomiting. Patient receives normal saline from 8:00 am to 11:00 am. Also received an IV push injection of Zofran at 10:30 am.
What service will be reported first?
Answer:
IV Push injection of Zofran .
The hydration is reported secondary with x3.

10. Let’s Talk Infusions

11. Getting a Line on IV Therapy
Infusions of fluids through a vein at a regulated rate is a method of intravenous (IV) therapy for the purpose of replacing fluid, maintaining fluid balance or adding medications or nutrients.
Hydration
An injection is the direct introduction of a drug or other fluid into the bloodstream or body tissue.
Hypodermic (SQ)
Intramuscular
Intravenous or IV push

12. Getting a Line on IV Therapy
IV push/bolus – Delivery of medication through an IV push is considered an injection. The injection is given via a syringe either directly into the vein, or into a side port of another infusion IV.
When rapid absorption of a medication is necessary an IV injection may be the selected method of treatment

13. Assigning the Initial Service Code
For facility reporting, the hierarchy should be utilized when determining what to code/charge first.
One code in each category of drug administration codes has been designated as the “initial” service
Chemo infusions (96413)
Chemo injections (96409)
Non-chemo, therapeutic infusions (96365)
Non-chemo, therapeutic injections (96374)
Hydration infusions (96360)

14. Assigning the Initial Service Code Cont’d
CPT instructs only one initial service should be reported even if different services are provided or even if a visit/encounter spans a calendar day.
When administering multiple infusions, injections or combinations, only one “initial” service code should be reported, unless protocol requires that two separate IV sites must be used – CPT and NCCI Edits manual
If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code from the appropriate section should be reported (CPT Manual)

15. Exceptions to the Rule!
Exception 1: Multiple initial services can be reported when two vascular access sites are started due to medical necessity
Exception 2: Multiple initial services can be reported when there is more than one encounter on the same date of service and when the same service is provided again.

16. Case Scenario
An order is given for a patient to come to the hospital twice a day to receive IV infusion of an antibiotic for 10 consecutive days.
Would it be appropriate to use the initial CPT code for each session?

17. Case Scenario
An order is given for a patient to come to the hospital twice a day to receive IV infusion of an antibiotic for 10 consecutive days.
Would it be appropriate to use the initial CPT code for each session? Answer: 96365

18. Additional Hours of Infusion
Guidelines instruct reporting the “each additional hour” infusion codes for infusion intervals of greater than 30 minutes beyond the 1 hour increment.
96366 – IV therapeutic infusion; each add’l hour
96415 – Chemotherapy administration, IV infusion; each add'l hour
Intravenous Infusion, hydration; each add’l hour

19. Therapeutic Infusions – Sequential
Sequential means “one after another”
One drug infused after another
To report a sequential infusion, an initial infusion must be present/charged and a new drug is infused
Two sequential infusion codes exist; one for a therapeutic/diagnostic/prophylactic infusion (96367) and one for chemotherapy sequential infusion (96417)

20. Therapeutic Infusions - Sequential
Example:
A patient is admitted to observation and the physician orders an antibiotic IVPB administered over one hour and an infusion of Dilaudid. The patient receives the first infusion from 12 pm to 1 pm and the next infusion from 1:30 pm to 2:30 pm.
What codes would be reported?

21. Therapeutic Infusions - Sequential
Answer:
96365 (IV infusion for therapy, prophylaxis or diagnosis; initial, up to 1 hour) for the first IV infusion of the antibiotic
96367 (IV infusion; additional sequential infusion, up to 1 hour) for the second pain medication administration

22. Therapeutic Infusions - Concurrent
Concurrent means “at the same time”
Multiple infusions are provided simultaneously through the same venous access site.
A single access site with a double lumen catheter with two bags hung.
Infusing through the same access

23. Therapeutic Infusions – Concurrent cont.
Concurrent means “at the same time”
Drugs aren’t typically mixed in one bag – there must be more than one bag.
“At the same time…not mixed in the same bag…there must be two separate bags.” CPT Assistant, Nov. 2006
Multiple substances mixed in one bag are considered to be one infusion and are not reported as a concurrent infusion. Each substance can be reported separately, but only one administration is reported.

24. Therapeutic Infusions – Concurrent
Example:
Chemotherapy infusion 9:00 AM until 11:00 AM – if a non-chemotherapy infusion was also 9:00 AM and ran until 10:00 AM, that would be coded as concurrent (96368).
The non-chemo infusion began at the same time as the chemotherapy infusion
If chemotherapy agents are given concurrently, report the unlisted chemotherapy administration code Due to evidence of current practice standards, there is not a code at this time for concurrent administration of chemotherapeutic drugs
The American College of Oncology has said it is practically unheard of to have two chemotherapy drugs running in the same line

25. Chemotherapy Infusion
Report chemotherapeutic drug administration for:
Anti-neoplastic drugs administered for non-cancer diagnoses (for autoimmune disorders)
CERTAIN Monoclonal antibody agents and other biologic response modifiers for non-cancer diagnosis (such as rheumatological disorders)
Remicade
Rituxan

26. Chemotherapy Infusion
Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration
Non-radionuclide
Anti-neoplastic drugs and agents for treatment of noncancer diagnoses (e.g., for autoimmune conditions)
Monoclonal antibody agents
Infliximab (Remicade)
Methotrexate (Chron’s Disease)

27. Let’s Talk IV Injections
Intramuscular
Subcutaneous
Intravenous
Intra-arterial

28. IV Push Injections
Hospitals are to report first hour infusion codes after 15 minutes of infusion. Infusions lasting 15 minutes or less should be billed as intravenous (or intra-arterial) pushes and must be coded accordingly.
A healthcare professional administering an injection is continuously present to administer and observe the patient.

29. IV Push Injections
Code CPT to report an IV push injection of a single or initial substance/drug.
Code CPT for each additional sequential IV push of a new substance drug
Code CPT for each additional sequential IV push of the same substance drug
For facility coding, do not report for a push performed within 30 minutes of a reported push of the same substance or drug
The same restriction of reporting IV push injections of the same substance/drug does not apply to IM/SQ injections (CPT 96372)
Source: Q/A #22 – AHA Coding Clinic for HCPCS, 3rd Quarter, Volume 6, Number 3

30. IV Push Injection Scenarios
Patient given four IV pushes of Demerol, you would assign:
96374 or depending on whether there were other drug administration services provided
and x3 (provided there was 30 minutes or more between each push).

31. IV Push Injection Scenarios
Patient given one IV push of Demerol and one IV push of Toradol –
Assign and (again depending on whether there was another initial service)
If another initial service was already reported, then assign x2 since these are two different substances

32. IM/SQ Injections
Intramuscular injection (IM) – medication is injected directly into the muscle tissue
Subcutaneous injection (SQ) – medication is injected into the subcutaneous tissue
Rules for “same substance” does not apply
Do not report for vaccines/toxoids

33. Hydration Coding
CPT defines hydrated based on the solutions (pre- mixed, D5-W, normal saline, pre-mixed electrolytes, lactated ringers, etc.)
A specific rate alone does not necessarily point to hydration vs. a therapeutic infusion
Hydration CPT codes cannot be reported for KVO (keep vein open), heplock/saline lock
A valid physician order is required for hydration
Medical Necessity

34. Hydration Coding Reason for hydration must be documented
There are many reasons and different diagnoses that may warrant an order for hydration, including diarrhea, nausea, vomiting, pain, dehydration, etc.
Report separately fluid administration that is medically necessary and can support separately billing the infusion (e.g., correction of dehydration, prevention of nephrotoxicity) before and/or after transfusion or chemotherapy

35. Hydration Coding Cont’d
96360 – IV infusion, hydration; initial, 31 minutes to 1 hour
Do not report if performed as a concurrent infusion service
Do not report IV infusion for hydration of 30 minutes or less
…each additional hour
Report for hydration intervals of greater than 30 minutes beyond 1 hour
Report to identify hydration if provided as a secondary or subsequent service after a different initial service is administered through the same IV access.
These are the codes used for hydration.
You wouldn’t report (the initial hydration code) if it’s performed concurrently with another infusion service since hydration is never the primary service when multiple services are performed.
The guidelines specifically instruct not to report hydration services that last 30 minutes or less.
You would report when there are 91 minutes or more of hydration provided – greater than 30 minutes BEYOND 1 hour.

36. Documentation Rules Order must be by a physician
Documentation must support medical necessity
EACH substance administered is clearly documented without the use of abbreviations
Route and site is easily discernible
Start and stop times for each substance is documented – this is the best practice
Amount of EACH substance given is documented
Copyright Sarasin Consulting Group 29
Many times I see “Toradol IV, Demerol IV” This is not clear as to what route of administration was used – IV infusion or IV push injection?
It’s recommended that specific documentation guidelines are established for drug administration services. If a drug is given as an IV push – then nursing could write “IVP”.
I’ve also seen some facilities come up with a list of drugs that are ONLY given as either IV infusions or as IV push injections.
Make sure these types of lists are continually updated. Facility had such a list – specific drug was always given as an infusion as on the list. Coders began seeing this same drug written as given by an IV push. Coder still reported the infusion; but in talking with the ED staff, they had started giving this particular drug as IV push.

37. Documentation Issues
Physician and nursing documentation is the key - without it, accurate coding/charging can not occur
Typically, hospital documentation for infusion services reflects the substance being infused and the flow rate…but this is not enough
Drug administration services that reference time are in fact “time-based” codes, therefore documentation should support the coding/billing
Accurate CPT code assignment depends on complete and thorough documentation.
Since CMS will now pay for additional hours of infusion time, it is critical for a facility to have complete and accurate documentation – this includes start/stop times.
Without clear guidelines from CMS, documentation requirements can be very confusing for both coders and clinicians.
It is important for the coding staff to work closely with nursing to help them understand the guidelines in order to appropriately document all services.

38. Documentation - Some Helpful Resources
Per AMA – “Infusion time is measured when the infusate is actually running: pre and post time are not counted. It is recommended to document infusion start and stop times.”
Per CMS IOM 100-4, Chapter 4, §230 – Hospitals are to report codes according to CPT instructions. CPT instructions are to use the actual time over which the infusion is administered to the beneficiary for time-specific drug administration codes.
CMS – Indicates that it has the expectation that hospitals will document time otherwise CMS has a difficult time understanding how services would be billed appropriately.
Here is what the American Medical Association and Medicare say about time based CPT codes.
You can see that CMS expects hospitals to document time.
Medicare says they have a hard time understanding how the codes are appropriately billed without the times documented.

39. Documentation - Some Helpful Resources
AdminaStar Dec 2006 FAQ #9:
“…the important thing to remember is that a reviewer must be able to determine the actual amount of time a medication infused from the records, not just the ‘ordered’ infusion time.”
Drug administration codes are “time-based” codes, therefore a “time-frame” should be clearly documented
Kansas Medicare—FAQ from December 2006:
“...Documenting the actual times would carve out any non-infusion time between each bag that is hung. It is this intermediary’s interpretation that the actual infusion start and stop times should
always be documented.”

40. Start and Stop Time Not Documented?
CMS does not state anything about what can/cannot be reported if an explicit “stop” time is missing…but several FIs have indicated that an IV push injection can be reported.
The coder(s) typically will recognize this and report an IV push when stop times are not reported.
What is your practice when a stop time is not reported?
What does your FI/MAC say?
If you FI/MAC doesn’t give specific guidelines, you should develop a policy for the coders on what to do in these cases.
Obviously, education should be provided to the nursing staff on good documentation practices and they should be alerted when this isn’t the case.
But – for those accounts where a stop time isn’t documented – the coders need to know what to do with these and they all need to be consistent.
Some facilities have a policy that if a start/stop times are not documented – they don’t report the charge at all.
Others may report these as IV push injections.
Whatever your policy is – be consistent. Susie Coder shouldn’t report IV push injections for these and Debbie Coder doesn’t report these at all.

41. Cross Over Dates
What do you do when the visit/encounter crosses the midnight hour?
Codes should be reported for the entire encounter
Report services using the actual date of service they were provided.
You may see multiple lines of the same CPT code with different dates
Do not report multiple initial service codes because the patient stays overnight
Even if the patient stays overnight, either in the ED or as an observation patient, you do not report multiple initial services.
Don’t start “counting” again after midnight – don’t treat as a separate encounter.
Always report the actual date of service the drug administration service was given
In 2012, CPT gave direction to report an initial code when services spanned over different dates of service, however CMS has given direction not to charge for the services that way when reporting facility services.

42. Cross Over Dates
Clarification to the 2012 CPT Infusion Therapy update on reporting hospital infusion services for outpatient facilities:
“For continuous services that last beyond midnight, use the date in which the service began and report the total units of time provided .”
The original example in the 2012 CPT book was revised.

43. Key Take-Always Documentation is key Accurately assign CPT codes
Physician order
Diagnosis supporting medical necessity
Start and stop time required
Accurately assign CPT codes
Keep up to date on changes
Review annual CPT updates
Review CMS transmittals
Monitor what the FI/MAC says
Maintain up-to-date CDM

44. Case Scenario #1
Patient comes to the ED on , and hydration is started at 10:00 p.m. It continues until 6:30AM on The patient received an IV push of morphine on 02/15/15 and again at 2AM on 02/16/15.
What CPT codes and units should be reported?

45. Answer! CPT codes to report would be:
96374 x 1 - 2/15/15 (morphine on 2/15/15)
96361 x 8 - 2/15/15 (hydration 10:00-6:30)
96376 x 1 2/16/15 (morphine on 2/16/15)

46. Case Scenario # 2
A physician orders one dose of a medication to be administered intramuscularly (IM) or subcutaneously (SQ). The volume required for this dose exceeds the amount recommended for a single injection, so the nurse must divide the dose into two IM/SQ injections. May we report one or two units of CPT code to report this service?
Reference APC Weekly

47. Answer!
Report the multiple IM/SQ injections with (therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) with the number of injections administered to the patient. Although medically unlikely edits (MUEs) exist for other drug administration codes, CMS has not published MUE limits for

48. Case Scenario #3
A patient is seen at our facility for concurrent chemotherapy administration. Leucovorin is administered intravenously for 2 hours. Oxaliplatin is administered via IV piggyback (IVPB) over the course of 2 hours and 20 minutes concurrently with the administration of Leucovorin. The administration of the Leucovorin is completed 20 minutes prior to the completion of the Oxaliplatin administration. . How should we report the concurrent chemotherapy administration?

49. Answer! Oxaliplatin – chemotherapy 2 hours
96413 (initial chemo infusion) x1
96415 (each additional hour chemo infusion) x1
Leucovorin – not considered a chemotherapy drug
96368 (concurrent infusion)
Leucovorin is similar to folic acid and is often administered with chemo drugs.
Used to either protect healthy cells from chemotherapy or to enhance the anti-cancer effect of chemotherapy.

50. Case Scenario #4
A patient was seen in the outpatient clinic for drug infusion. The physician ordered antibiotic drug infusion every 12 hours, with the first antibiotic infusion followed by an antifungal drug infusion. The patient received the infusion at 8:00 AM and was permitted to leave the center. The patient then returned later in the day to receive the second infusion at 8:00 PM.
Would it be appropriate to report two initial infusions (code 96365) with modifier -59  appended to represent the second dose?

51. Answer!
It is appropriate to append modifier -59, Distinct Procedural Service, to the second initial service, whether it is for a second encounter on the same date of service or second site per protocol. In this circumstance, the second initial service is reported because the patient left the center and upon returning, another initial infusion is administered.
It is recommended that you provide medical documentation based on payer policy regarding the use of the same "initial" infusion code on the same date of service with modifier -59 appended. 

52. Case Scenario #5
Physician orders the following and patient receives the following:
Toradol 30 mg IVP
Zofran 4 mg IVP
Decadron 20 mg IM
Demerol 25 mg IVP
Rocephin 1 gram IVP
IVF 1 liter NS for 1 hour
This was taken from an actual hospital case.

53. Answer! The facility may report the following: 96374 IVP Toradol;
96375 IVP Zofran;
96372 IVP Decadron;
96375 IVP Demerol;
96375 IVP Rocephin;
96376 IVP Toradol;
96361 IV 1 liter NS
Remember that the hydration is questionable because documentation has to support the medical necessity for the hydration service. Also, is charged for each different medication administered via IV push. When hydration is reported with IV medications, it is charged with the additional hour code.

54. Resources and References
Federal Register OPPS Final Rule
CMS Transmittals -
2015 OPPS Drug Administration
CPT Codebook, 2015
Chapter guidelines, individual code notes and section notes
CPT Assistant
Coding Clinic for HCPCS

55. Questions