Infusion / Injection / Hydration - Healthcare Professionals

Presented by:Vivian Blankemeier, CCSPatricia Vargas, CCSPrepared by:Christi Gonzales, CCSS&W Healthcare

Codes for injections and infusions compriseonly five pages of the more than 700 in theCPT manual, yet they continue to be amongthe most difficult for coders to decipher.S&W Healthcare

Review of ConceptsHierarchyCode DefinitionsDocumentationTimePhysician OrderSubstance AdministrationConcurrent vs. Sequential InfusionHydrationTips/ExercisesS&W Healthcare

The CPT guidelines and hierarchy must befollowed:◦ One code in each category of intravenous infusion and injectiondrug administration codes designated as the “initial” service.◦ Order of service delivery does NOT determine what is “initial”.◦ Typically only one “initial service” will be reported per encounterunless there is more than one IV access site.• Chemo services are primary to therapeutic, prophylactic, and diagnosticservices, which are primary to hydration services.• Infusions are primary to pushes, which are primary to injections.• The hierarchy does not apply to physician reporting.• The hierarchy does not apply to SQ/IM injections, only intravenousinjections.S&W Healthcare

Facility coding of the “Initial” code should beselected using the hierarchy below:◦ Chemotherapy Infusions◦ Chemotherapy Injections◦ Therapeutic, Prophylactic and Diagnostic Infusions◦ Therapeutic, Prophylactic and Diagnostic Injections◦ Hydration InfusionsWhen coding injections and infusions, always followthe hierarchy regardless of the order in which serviceswere provided. Chemotherapy services are alwaysprimary, meaning you must report them first.S&W Healthcare

Infusion Therapy 96365-96368◦ For purposes of facility coding, an infusion is required tobe more than fifteen (16+) minutes for safe and effectiveadministration. Injection/IV Push Therapy 96374-96376◦ An intravenous injection (IV push) is an infusion offifteen minutes or less. Hydration Therapy 96360-96361 IM/Subcutaneous Injection 96372S&W Healthcare

Codes Description Time Duration96360 Intravenous infusion;Hydration; initial, 31minutes to 1 hour96361 Intravenous infusion;Hydration; eachadditional hour96365 Intravenous infusion;for therapy,prophylaxis, ordiagnostic; initial, upto 1 hour‣ 31 minutes to onehour‣ Do NOT reporthydration infusionsof 30 minutes orless‣ Beginning at 91minutes‣ 16 minutes to onehour‣ Infusion less than15 minutes = IVPS&W Healthcare

Codes Description Time Duration96366 Intravenous infusion,for therapy,prophylaxis, ordiagnostic; eachadditional hour (listseparately in additionto primary code)‣ Beginning at 91minutes‣ Same Drug96367 Intravenous infusion,therapy, prophylaxisor diagnostic;additional sequentialinfusion, up to 1 hour(list separately inaddition to primarycode)‣ Different Drug‣ Additional hourswill be reportedusing 96366S&W Healthcare

Codes Description Time Duration96368 Intravenous infusion,for therapy,prophylaxis, ordiagnostic; concurrentinfusion) listseparately in additionto primary code) ONCEper day96372 Subcutaneous or IMinjection96374 Therapeutic,prophylactic ordiagnostic injection;IVP, single or initialsubstance/drug‣ 16 to 90 minutes‣ Can only be billedONCE regardless ofthe duration of theconcurrent infusion‣ No restrictions onmultiple injections‣ 15 minutes or less‣ Do NOT report thiswith InitialTherapeuticInfusion (96365)unless meetscriteriaS&W Healthcare

Codes Description Time Duration96375 Therapeutic,prophylactic ordiagnostic injection;each additionalsequential IV PUSH ofa NEW substance/drug(list separately inaddition to code forprimary procedure96376 Same as Above exceptSAME drug‣ 15 minutes or less‣ NEW drug‣ 15 minutes or less‣ SAME drug‣ Must be 30 minutessince initial pushS&W Healthcare

90460 – 90474 Code only one INITIAL immunizationadministration per visit Follow same rules as injections/infusions Parentheticals below immunization codesclearly state which combinations are notallowed to be billed togetherS&W Healthcare

IM or Subcutaneous Injections: 96372 Multiple IM/Subcutaneous Injections:◦ Same drug/substance can be reported as long as itis ordered and documented◦ There are no time restrictions/guidelines present atthis time◦ Documentation needs to be made of site and timeS&W Healthcare

Some answers:◦ Per AMA – “Infusion time is measured when theinfusate is actually running: pre and post time arenot counted. It is recommended to documentinfusion start and stop times.”◦ Per CMS IOM 100-4, Chapter 4, 230 – “Hospitals areto report codes according to CPT instructions. CPTinstructions are to use actual time over which theinfusion is administered to the beneficiary for timespecificdrug administration codes.”◦ CMS – Indicates that it has the expectation thathospitals will document time otherwise CMS has adifficult time understanding how services would bebilled appropriately.S&W Healthcare

Physician and nursing documentation are thekey for accurate charging. Typically, hospital documentation for infusionservices reflect the substance being infusedand the flow rate…but this is not enough. Drug administration services that referencetime are in fact “time-based” codes, thereforedocumentation should support the billedcharges.S&W Healthcare

Time Documentation is Critical and Drives theAccuracy of the Codes Reported:◦ Less than 15 minutes◦ More than 15 minutes (16+)◦ 31 minutes to 1 hours◦ 15 to 90 minutes vs more than 90 minutes (91)◦ 30 minutes since the last reported push◦ Greater than 30 minutes beyond 1 hour increments(91)S&W Healthcare

The infusion time is defined as the actualtime over which the infusion is administered.Infusion time is calculated from the time theadministration commences (i.e., the infusionstarts dripping) to when it ends (i.e., theinfusion stops dripping). Intravenous or intra-arterial pushadministration are differentiated from theother infusion services and defined as“infusion of 15 minutes or less”.S&W Healthcare

Billing and Coding for Infusions need:◦ Name of the Drug◦ Strength of the Drug◦ Method of Administration◦ Time-Time-TimeS&W Healthcare

The Rules for Documentation:◦ Must be ordered by a physician◦ Documentation must support medical necessity◦ EACH substance administered is:• Clearly documented, no abbreviations• Route and Site are easily discernible• Start and stop times for EACH substance aredocumented• This is the best practice• Amount of EACH substance given is documentedS&W Healthcare

Sometimes It’s OK to Have More Than OneInitial or Primary Service CodeSeparate SiteSeparate Encounter2 am4 pmTo report 2 different “initial” servicecodes use Modifier -59.S&W Healthcare

A Concurrent Infusionoccurs when multipleinfusions are providedsimultaneously throughthe same intravenousline.S&W Healthcare

Sequential is one after the other through thesame venous access site. Concurrent is at the same time through thesame access site (but may be through adifferent lumen of the catheter). Multiple drugs added to one bag of fluids areNOT a concurrent infusion.S&W Healthcare

Hydration is considered an infusion ofprepackaged fluid for the purpose of restoringbodily fluid. There must be physiciandocumentation of medical necessity to charge forhydration. This includes but not limited to:Dehydration/Volume DepletionInability to maintain fluid intake (i.e., nausea &/vomiting)Sugar &/ electrolyte imbalancesDiarrheaPain*NOTE: Hydration cannot be reported for TKO, KVO, Heplock, Saline LockS&W Healthcare

Only one “initial” service code should be reported, unless twoseparate IV sites are required; Hydration codes are reported after 30 minutes of infusion(31)/Do not charge hydration when provided for 30 minutes orless; Concurrent infusion is only reported once per encounter; Sequential is one after the other; concurrent is at the same time.In order to report a concurrent administration, the drugs cannotsimply be mixed in one bag; there must be more than one bag; Infusions of 15 minutes or less are reported with an IV pushcode; Injections are coded per injection, not per medication; Each additional sequential IV push of the same substance mustbe greater than 30 minutes; Vaccination codes utilize an administration code 90465-90474in addition to the vaccine/toxoid 90476-90479;S&W Healthcare

Do not charge for hydration and infusion during the sametime interval;Hydration consists of pre-packaged fluid and electrolytes(e.g., normal saline, D5 ½ normal saline + 30 mEq KCl/liter);Do not charge for services integral to a procedure (e.g., drugsgiven during CPR or prior to intubation);Infusion is for the administration of substances/drugs. Whenfluids are used to administer the drug(s), the administrationof the fluid is considered incidental hydration and is notseparately reportable;Hydration is not coded on a concurrent service.S&W Healthcare

Contrast Epinephrine Surgeryduring during CPR orCT ScanRecoveryS&W Healthcare

If performed to facilitate the infusion orinjection, the following services are includedand are not reported separately:◦ Use of local anesthesia◦ Intravenous (IV) start◦ Access to indwelling IV, subcutaneous catheter orport◦ Flush at conclusion of infusion◦ Standard tubing, syringes and supplies◦ Preparation of the chemotherapy agent(s)S&W Healthcare

To begin, select one column based on the facilityhierarchy whereby infusion is first, IV push is second andhydration is third. Mark all remaining charges in thatcolumn. If a patient does not receive an IV infusion, startwith the IV push column. If a patient does not receive aninfusion or an IV push, start with the hydration column.S&W Healthcare

MEDICATION INFUSION____96365 Initial Infusionup to 1 hour____# hours 96366 Eachadd’l hour (after 31 min)____# 96367 Sequentialinfusion up to 1 hour (use96366 for add’l hours ofsequential infusion)____96368 Concurrentinfusion – Report only onceper encounter____# 96375 IV Push Eachpush of different drug____# 96376 Each IV pushof same drug at intervals >30min____# hours 96361Hydration – Do not chargeduring same time of infusion,must be at least 31 min____# 96372 IM/SQinjection____90471 IM/SQ vaccineIV PUSH____96374 Initial Push orInfusion 30min____# hours 96361Hydration – Must be at least31 minutes____# 96372 IM/SQinjection____90471 IM/SQ vaccine____# 90472 Each add’lIM/SQ vaccineHYDRATION____96360 Initial hydrationup to 1 hour – must be atleast 31 min____# hours 96361Hydration Each add’l hour(after 31 min)____# 96372 IM/SQinjection____90471 IM/SQ vaccine____# 90472 Each add’lIM/SQ vaccineS&W Healthcare

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Jane Smith comes into the ER with vomiting.Dr. Roberts orders an IV push of Zofran and IVhydration for dehydration. The nursedocuments that she administered the IV push at1:44 p.m. She also documents that she startedthe hydration at 2:05 p.m. and discontinued itat 4:10 p.m. How do you code theinjections/infusions on this case?S&W Healthcare

96374 – IVP 96361 x 2 - HydrationS&W Healthcare

A 66-year-old patient arrives to the ER andreceives a therapeutic infusion from 10:15am to 11:55 a.m. The patient receives an IVpush of the same drug at 1:00 p.m.How is this reported?S&W Healthcare

96365 – 1 st hour of infusion 96366 – 2 nd hour of infusion 96376 – IVP of the same drugS&W Healthcare

A 54-year-old patient comes to the ERcomplaining of pain in his legs and backsaying he feels nauseous and lightheaded.The ER starts an IV and begins hydration from7-7:25 a.m. and IVP of Morphine is given at8:00 a.m. How is this reported?S&W Healthcare

96374 – IVP of Morphine No code is assigned for the hydration sincethe time is less than 30 minutes.S&W Healthcare

Patient has the following:◦ Lasix IVP @ 10:00 a.m.◦ Lasix IVP @ 10:25 a.m.◦ Phenergan IVP @ 10:40 a.m.◦ Lasix IVP @ 1:00 p.m.◦ Lasix IVP @ 3:00 p.m.◦ How is this reported?S&W Healthcare

96374 x 1 – Initial IVP Lasix 96375 x 1 – IVP different drug (Phenergan) 96376 x 2 – IVP same drug (Lasix) NOTE- Lasix IVP at 10:25 cannot be billedsince it had not been 30 minutes since initialpush.S&W Healthcare

Patient presents to the ER in respiratoryfailure. Patient was administered an IVP ofEtomidate at 0200 and was intubated. Patientwas placed on a ventilator and maintainedgood oxygen saturations. Patient’s heart ratedipped to 50 but responded to IVP ofAtropine at 0300. Patient infused withVancomycin from 0325-0435. Levaquininfused from 0345-0420. How would this be reported?S&W Healthcare

96365 – Initial Infusion of Vancomycin 96367 – Sequential Infusion of Levaquin 96375 – IVP Atropine (different drug) Etomidate would not be charged sinceintegral to the intubation.S&W Healthcare

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