1. Drug Administration Uglies “Injections & Infusions Made Easy for 2019”.

2. Let’s Take a Closer Look
2019 Drug Administration CPT codes and rules
Same ‘Renumbered’ CPT codes since
2009
Review clinical scenarios related to some
of these codes
Review documentation requirements and better practices
Time Documentation (start & stop)
Using Modifier -59 with Drug Administration
Services

3. Drug Administration Challenges For 2019
High area of lost revenue: ER to OBS, Direct admit to OBS, and O.R. to OBS.
Co-mingling inpt and obs beds = highly problematic time charting for drug administration.
Focus nursing on charting start and stop times to capture every minute.
Charge capture is highly complex for nursing. Does it make sense to have a dedicated ‘charge capture analyst? (Track and trend/TNT variances too)

4. 2019 Drug Administration “Uglies”
Initial/primary reason for visit
Use 9xxxx codes for all payers. C code/pump for Medicare only
Once determined, initial/primary visit code (hydration, therapeutic, chemo)- then use subsequent CPTs for additional services
All outpatient areas are impacted: ER, Observation, Hospital Based Clinics (HBC)
IDEA: Nursing takes ownership for charting ‘stop and stop’ times per CPT
IDEA: Create Charge Capture Analyst position

5. Drug Administration
Need to continue following CPT guidelines and instructions and MUST review CPT descriptors and parenthetical notes carefully!
From the hydration, therapeutic, prophylactic,
and diagnostic injections & infusions section/9xxxx:
“. The CPT Manual “Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration” section guidelines state “If performed to facilitate the infusion or injection, the following services are included and are not reported separately”: access, flushes and standard tubing, syringes and supplies.”

6. Drug Administration Changes?
Nope…still the same! CPT has outlined a hierarchy from Nov 2005 CPT Assistant which takes the guess work out of trying to figure out which drug administration service should be the initial, subsequent, etc.
“Initial” code should be selected using a hierarchy whereby:
Chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration services.
Infusions are primary to pushes, which are primary to injections.

7. Question: Does the fact that infusions are primary to pushes mean that hydration is primary to a IV push?
Answer: No, because the first sub-bullet indicates that therapeutic, prophylactic and diagnostic services are primary to hydration services; an IV push is considered a therapeutic, prophylactic, or diagnostic service, therefore it is primary to hydration. HINT: Given first in the course of treatment DOES NOT mean it is primary or initial.

8. Clarification Please!
The CPT statement is: “The initial code should be selected using a hierarchy whereby chemotherapy SERVICES are primary to therapeutic, prophylactic, and diagnostic SERVICES, which are primary to hydration SERVICES. Infusions are primary to pushes, which are primary to injections.”
Within each “code set” have a further breakdown of the type of delivery/route/method (infusion, then the push, then the injection).
Since hydration is the last code set, and there is only one method (infusion), it would always be secondary to any other medication administrations.

9. Additional 2019 CPT Notes
When administering multiple infusions, injections or combinations, only 1 initial service code should be reported, unless protocol requires that 2 separate IV sites must be used and is medically necessary. (CMS 230-Billing & payment for drug adm,.)
If the ER to obs spans more than 1 day, look at the entire stay and determine the hierarchy. 1 initial and then subsequent.
If a significant separately identifiable E&M service is performed, the appropriate E&M service code should be reported using modifier -25 in addition to
For same day E&M service a different diagnosis is not required.

10. More CPT Notes… Nothing New
If performed to facilitate the infusion or injection, the following services are included and are not separately billable:
Use of local anesthesia
IV start
Access to indwelling IV, subcutaneous catheter or port
Flush
Standard tubing, syringes and supplies

11. IV Therapeutic Infusions & Injections
Chemotherapy CPT codes (renumbered) in 2009 – still the same for 2019
Same 2019 CPT Codes: – 96379
Same Heading:
Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration

12. Drug Administration Codes
CPT 96360: Intravenous infusion, hydration; initial, 31
minutes to 1 hour
Note! Must reach 31 minutes in order to bill infusion
In 2007 we had 16 minutes (history tidbit)
Do not report hydration infusions of 30 minutes or less! No CPT code for this! NON BILLABLE!
Hydration – IV infusion to consist of a pre-packaged fluid and electrolytes (i.e. normal saline, D5 ½ normal saline +30mEq KCL/liter), but are not used to report infusion of drugs or other substances.
“TKO” (to keep open) & “KVO” (keep vein open) cannot be charged. CAREFUL documentation of ‘therapeutic ‘ with low rates.

13. Clinical Example # 1 ER patient presents with a laceration
to the forehead
Service
Time
Description
2019 CPT Code
Laceration repair
5:30
Laceration repair with Xylocaine
Depends on documentation
IVPB
5:00 – 5:20
Normal saline wide open
No CPT code
IVP
6:00
Morphine
96374 x 1
Blood transfusion
7:00 – 9:30
Transfusion
2 units whole blood
36430 x 1
P9010 x 2

14. List separately in addition to code for primary procedure)
More CPT Codes for 2019
CPT 96361: Intravenous infusion, hydration; each additional hour
List separately in addition to code for primary procedure)
Add-on code (+)
Start and stop of bags must be present. Add all time- ER to OBS

15. Still More…
CPT 96365: Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour
CPT 96366: Intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour
List separately in addition to code for primary procedure).
Add-on code (+)
Need start and stop. W/O –check with MAC to bill for a single push instead of actual time..

16. CPT 96367: Intravenous infusion, for therapy, prophylaxis, or diagnosis; additional sequential infusion, up to 1 hour
List separately in addition to code for primary procedure
Coding Tip! Do not report more than once per sequential infusion of the same mix.

17. CPT 96368: Intravenous infusion, for therapy, prophylaxis, or diagnosis; concurrent infusion
List separately in addition to code for primary procedure

18. And a Few More CPT Codes!
CPT 96369: Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s).
CMS Guidance: For infusions of 15 minutes or less, report with CPT code x1 (SUB/IM INJECTION)
Additional guidance:
Involves the placement of multiple subcutaneous accesses to infuse immune globulin
Includes an infusion pump to administer the infusion

19. CPT 96370
CPT 96370: Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour
List separately in addition to code for primary procedure
Add-on code (+) = Must be reported with
CPT code 96369
For infusions greater than 30 minutes
beyond one hour increments

20. CPT 96371: Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s).
Report with CPT code 96369
Report only 1 time per day
CMS Guidance: “Captures the practice expense of obtaining additional accesses and the set up of a pump for infusions in larger individuals”.

21. CPT 96372: Therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular (SC/SQ or IM)
Only CPT code that does NOT follow the CPT hierarchy – rules do not apply
Can report multiple SC/SQ/IM injections of the same substance/drug

22. More CPT Codes!
CPT 96373: Therapeutic, prophylactic or diagnostic injection, intra-arterial
CPT 96374: Therapeutic, prophylactic or diagnostic injection; IV push, single or initial drug

23. Then There is CPT Code 96375…
CPT 96375: Therapeutic, prophylactic or diagnostic injection; each additional sequential IVP of a new substance/drug
List separately in addition to code for primary procedure
Add-on code (+)

24. Confusion Still Exists!
CPT 96376: Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential IV push of the same substance/drug provided in a facility
Be careful! Code cannot be reported if a push of the same substance or drug occurred within 30 minutes (pushes of same substance or drug must be “31 “minutes apart)
Example: Four hourly IVPs of Demerol would be reported as x 1 & x 3 as long as the time requirement is met
Is the time documented in your medical record?

25. Using CPT Correctly
Report multiple individually prepared administrations as individual drug administrations.
If the drug or substance is prepared one time and then administered in portions, report the administrations as only one administration, i.e. CPT
If the clinician administers a 2nd, separately prepared same drug in portions, this would equal a single admin of the same drug beyond a
30-minute interval (CPT 96376).

26. Now For The Bad News…
Medical record documentation by the clinician does not easily allow a coder to determine whether the IV pushes were individually prepared or administered in portions.
Still no separate APC payment assigned to this code for 2019/97 as it 96376is still packaged.

27. Clinical Example # 2 IVP 1000 Lasix 96374 x 1 1110 96376 x 1 1300 1500
Service
Time
Description
2019 CPT Codes
IVP
1000
Lasix
96374 x 1
1110
96376 x 1
1300
1500

28. Same drug, not 30 mins since previous
Clinical Example # 3
Service
Time
Description
2019 CPT Codes
IVP
1000
Lasix
96374 x 1
1018
No code – Why?
Same drug, not 30 mins since previous
1300
96376 x 1
1500

29. Selecting Initial, Sequential & Concurrent CPT Codes
Initial –CMS 230-Billing & payment for drug adm
Code that best describes the key or primary reason for the visit but must follow hierarchy.
One code in each category of IV infusion and IV push drug administration codes has been designated as the “initial” service
Order of service delivery does NOT determine what is “initial”
Only one “initial” service should be reported per encounter UNLESS:
Protocol requires two separate IV sites
Multiple encounters are provided on the same DOS
Other drug administration services are also provided by a different route other than IV infusion or IV push

30. Question: How is the initial service selected?
Answer: The “initial” code that best describes the key or primary reason for the encounter should always be reported regardless of the order in which the infusions or injections were given BUT FOLLOW Hierarchy!
This was not always clear in the past, but now the 2019 CPT book makes it explicit with a hierarchy!
Chemo infusions
Chemo injections
Non-chemo, therapeutic infusions
Non-chemo, therapeutic injections
Other injections
Hydration infusions

31. Sequential/Subsequent
Add-on codes (think “one after another” or “before or after the initial drug service”)
Should be used in addition to an “initial” code and the order of the services given does not matter
Reported once per encounter for the same infusate mix; additional hours reported with additional hours therapeutic infusion code (96366); and it is okay to report multiple sequential infusion codes if multiple different drugs are given

32. Question: How should an IV infusion of the same infusate that’s given multiple times during 1 visit be reported?
Answer: For example, calcium and magnesium are combined with D5W in an IV bag and one 20 minute infusion is given pre-chemo and one 20 minute infusion is given after chemo. This infusion would be billed as one sequential infusion, up to 1 hour (96367).
The two 20-minute infusions of calcium/magnesium would be added together for a total of 40 minutes.

33. Concurrent (think “at the same time”)
Add-on code when multiple infusions are provided simultaneously through the same IV line, even with different bags.
No code for concurrent administration of chemo drugs, but if it does happen, then the unlisted chemo admin code should be reported.
Multiple substances mixed in one bag are considered to be one infusion, not a concurrent infusion.
There is no concurrent code for hydration.

34. Concurrent Hydration with Separate Access Sites
If a separate venous access site is started for hydration along w/ another venous access site for a therapeutic infusion, report an “initial” code for the hydration and the appropriate “initial” code for the other infusion access site.
Note! CPT Manual makes it clear that hydration running concurrently through the same access site is still not separately reportable.

35. Key Concepts for Reporting
IV infusion of short duration is still defined as 15 minutes or less - report with an IV push injection code.
Initial or 1st hour of infusion is from 16 to 90 minutes
Applies to therapeutic infusions but not to hydration/.
Additional hours of infusion
Report add-on codes for additional hours of infusion (beyond the 1st hour) only after more than 30 minutes have passed from the end of the previously billed hour, i.e., 91/1st hr and then 31 additional mins/next hr would allow an additional hour to be charged.

36. Time Documentation
Per AMA – “Infusion time is measured when the infusate is actually running: pre and post time are not counted. It is recommended to document BOTH infusion start and stop times.”
Per CMS – “Hospitals are to report codes according to CPT instructions. Are to use the actual time over which the infusion is administered to the patient for time-specific drug administration codes.”
Remember 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.

37. What If There Is “NO” Stop Time Documented?
Do you report an infusion, injection, or nothing when the stop time is missing?
CMS has stated that a short-duration infusion (i.e. less than 15 minutes) can be reported as an IV push injection……. therefore, if there is no stop time, would the infusion automatically be 15 minutes or less……since you don’t know if it was more?
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.
Remember, if there is no stop time for hydration you cannot report anything unless 30 minutes is charted.

38. Better Practice of Course…
Better practice is to require start and stop times for all drug administration services!
Regardless of how the charges are created, nursing's charting of start & stops does not change.
If multiple IV access sites are required, there must be separate start and stop times documented for each IV access site.
Can be challenging for nursing to document!

39. Drug Admin Integral to Procedures
If the drug administration service is typically performed pre- or post-procedure, then you do not separately report.
Examples: Infusion of anesthetic for surgery; pre-op antibiotic injection/infusion; post-op pain and/or nausea injections; injections during CPR; injections for sedation analgesia
If the drug administration services is not typical for the procedure, then you do report it separately.
Examples: Anti-thrombolytic injection either pre- or post-surgery; anti-hypertensive injection

40. Hot Spots to Watch Out For!
ER to OBS
Handoff from ER to OBS – Do you maintain 2 separate nursing documentation tools? Are the drug administration services being captured correctly from the ER to OBS?
PP (Post-Procedure) to OBS
Cannot bill observation until 4-6 hours of routine recovery has passed unless abnormal event during the surgical case.
Direct Admit to OBS
Nursing needs to document all drug administration services as well as any bed-side procedures.

41. Using Modifier 59
Modifier 59 must be used in specific situations and you may find that you are using them more frequently than what was initially expected.
Use Modifier 59 if two vascular access sites are started.
Use Modifier 59 if multiple encounters occur on the same date of service.
CCI edits for drug admin are being applied in full, therefore the traditional rules for modifier 59 are in effect.
Be careful! Modifier 59 is a hot spot right now with the OIG (Office of Inspector General) and they are looking closely at the usage.

42. Using Modifier 59
Most frequent CCI edit: When two initial CPT codes are paired together you will receive an edit message:
“Code is a component of code but a modifier is allowed in order to differentiate between the services provided.”
You can only have one “initial” service per IV site per encounter, unless multiple lines are started.
Just because the edit appears does not mean you should add it just to get it out the door!
Stop! Need to research why there was a rejection. NEED THE MEDICAL RECORD!

43. Dates of Service for Drug Admin
What happens when the visit crosses the midnight hour?
During the January 2008 Open Door Forum call, CMS indicated that multiple “initial” service CPT codes should not be reported for a single encounter, even if the encounter crosses dates of service.
Do not “reset” the initial service CPT definitions just because the encounter has crossed the midnight hour.
Example: If a patient is in the ER on , and IV hydration is 10:00pm and continues until 2:00am, how would this look?
96360 x 1 on
96361 x 1 on
96361 x 2 on

44. AR Systems’ Contact Info
Day Egusquiza, President
AR Systems, Inc
Box 2521
Twin Falls, Id
Input from Karen Kvarfordt, President, Diagnosis Plus, Inc
Input from Dena Knippen, Critical Elements, LLC (CC auditor)
NEW EXPANDED WEBPAGE:
2020