Understanding Injections and Infusions in Healthcare

 
Injections and Infusions
 
Lamon Willis
 
Determining the Hierarchy
 
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)
 
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.
 
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?
 
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:
96374- IV Push injection of Zofran 
.
The hydration is reported secondary with 96361 x3.
 
Infusions
 
IV Infusion 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
 
IV Infusion 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
 
IV Infusion Therapy
 
Assigning the Initial 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)
 
IV Infusion Therapy
 
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
 
IV Infusion Therapy
 
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)
 
IV Infusion Therapy
 
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.
 
IV Infusion Therapy
 
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?
 
IV Infusion Therapy
 
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
 
IV Infusion Therapy
 
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
96361- Intravenous Infusion, hydration; each add’l hour
 
IV Infusion Therapy
 
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)
 
IV Infusion Therapy
 
Sequential
Sequential means “one after another”
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
96361- Intravenous Infusion, hydration; each add ’l
hour
 
IV Infusion Therapy
 
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?
 
IV Infusion Therapy
 
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
 
IV Infusion Therapy
 
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
 
IV Infusion Therapy
 
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.
 
IV Infusion Therapy
 
Example:
Chemotherapy
 infusion begins @ 9:00 AM until 11:00 AM – if a
non-chemotherapy
 infusion was also initiated @ 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 96549.   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
 
Chemotherapy Infusion
 
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
 
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)
 
IV Injections
 
IV Injections
 
Intramuscular
An intramuscular injection is a technique used to deliver
a medication deep into the muscles. This allows the
medication to be absorbed into the bloodstream
quickly.
Intramuscular injections are used when other types of
delivery methods aren’t recommended. These include:
oral (swallowed into the stomach)
intravenous (injected into the vein)
subcutaneous (injected into the fatty tissue just under
the layer of skin)
 
IV Injections
 
Subcutaneous
A subcutaneous injection is a method of
administering medication. Subcutaneous means
under the skin.
In this type of injection, a short needle is used to
inject a drug into the tissue layer between the skin
and the muscle.
Medication given this way is usually absorbed more
slowly than if injected into a vein, sometimes over a
period of 24 hours.
 
IV Injections
 
Intravenous
Hypodermic injection into a vein for the purpose of
instilling a single dose of medication, injecting a
contrast medium, or beginning an IV infusion of
blood, medication, or a fluid solution, such as
saline or dextrose in water.
Allows larger amounts of fluid to be administered
and provides means for rapid absorption of
medication.
 
 
IV Injections
 
Intra-arteria
l
Under special circumstances providers do inject
substances into an artery, taking all precautions needed to
e.g. prevent blood spill or bleeding afterwards, e.g.
injecting blood vessel dilatory drugs like Methyldopa in
conditions:
where arteries spasm causing lack of blood mostly in hand/feet
fingers/toes in Raynaud's disease,
in inoperable tumors sometimes blood clots or other solids are
injected into the artery that feeds the tumor, thus causing the
tumor to (partially) die off because of the lack of blood feeding it
so slow the growth and make it more sensitive to chemotherapy
and radiation treatment (i.e., Catheter Embolization), and
then in rare cases chemotherapy is administered into the artery
feeding the tumor which might be in the pancreas, liver, and
brain.
 
 
IV Push Injection
 
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.
 
IV Push Injection
 
Code CPT 96374 to report an IV push injection of a single or initial
substance/drug.
Code CPT 96375 for each additional sequential IV push of a 
new
substance drug
Code CPT 96376 for each additional sequential IV push of the 
same
substance drug
For facility coding, do not report 96376 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, 3
rd
 Quarter,
Volume 6, Number 3
 
IV Push Examples
 
Patient given four IV pushes of Demerol, you
would assign:
 
96374 or 96375 depending on whether there were
other drug administration services provided
and 96376 x3 (provided there was 30 minutes or more
between each push).
 
IV Push Examples
 
Patient given one IV push of Demerol and one IV push
of Toradol –
 
Assign 96374 and 96375 (again depending on whether there
was another initial service)
If another initial service was already reported, then assign
96375 x2 since these are two 
different
 substances
 
IV Push Examples
 
Patient given one IV push of Demerol and one IV push
of Toradol –
 
Assign 96374 and 96375 (again depending on whether there
was another initial service)
If another initial service was already reported, then assign
96375 x2 since these are two 
different
 substances
 
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 96372 for vaccines/toxoids
 
Hydration Therapy
 
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
 
Hydration Therapy
 
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
 
Hydration Therapy
 
96360 – IV infusion, hydration; initial, 31 minutes to 1
hour
Do not report 96360 if performed as a concurrent infusion
service
Do not report IV infusion for hydration of 
30 minutes or less
96361 - …each additional hour
Report 96361 for hydration intervals of greater than 30
minutes 
beyond
 1 hour
Report 96361 to identify hydration if provided as a
secondary or subsequent service after a different initial
service is administered through the 
same
 IV access.
 
Documentation Guidelines
 
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
 
Documentation Guidelines
 
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
 
Documentation Guidelines
 
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.
 
Documentation 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.”
 
Start & 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.
 
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
 
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.
 
Case Scenario 1
 
Patient comes to the ED on 02-15-15, and
hydration is started at 10:00 p.m. It continues until
6:30AM on 02-16-15. 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?
 
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
)
 
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 96372 to report this service?
 
Answer
 
Report the multiple IM/SQ injections with 96372
(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 96372.
 
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?
 
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.
 
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?
 
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.
 
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
Toradol 30 mg IVP
IVF 1 liter NS for 1 hour
 
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
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Determining the hierarchy of injections and infusions is crucial in medical coding and billing. Infusions are prioritized over pushes, which are prioritized over injections. This hierarchy should be followed for accurate reporting and coding. IV Infusion Therapy involves administering fluids or medications intravenously to maintain fluid balance or deliver nutrients. Understanding these distinctions is essential for healthcare providers to accurately document and report services provided.


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  1. Injections and Infusions Lamon Willis

  2. Determining the Hierarchy

  3. 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)

  4. 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.

  5. 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?

  6. 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: 96374- IV Push injection of Zofran . The hydration is reported secondary with 96361 x3.

  7. Infusions

  8. IV Infusion 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

  9. IV Infusion 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

  10. IV Infusion Therapy Assigning the Initial 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)

  11. IV Infusion Therapy 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

  12. IV Infusion Therapy 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)

  13. IV Infusion Therapy 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.

  14. IV Infusion Therapy 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?

  15. IV Infusion Therapy 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

  16. IV Infusion Therapy 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 96361- Intravenous Infusion, hydration; each add l hour

  17. IV Infusion Therapy 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)

  18. IV Infusion Therapy Sequential Sequential means one after another 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 96361- Intravenous Infusion, hydration; each add l hour

  19. IV Infusion Therapy 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?

  20. IV Infusion Therapy 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

  21. IV Infusion Therapy 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

  22. IV Infusion Therapy 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.

  23. IV Infusion Therapy Example: Chemotherapy infusion begins @ 9:00 AM until 11:00 AM if a non-chemotherapy infusion was also initiated @ 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 96549. 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

  24. Chemotherapy Infusion

  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. IV Injections

  28. IV Injections Intramuscular An intramuscular injection is a technique used to deliver a medication deep into the muscles. This allows the medication to be absorbed into the bloodstream quickly. Intramuscular injections are used when other types of delivery methods aren t recommended. These include: oral (swallowed into the stomach) intravenous (injected into the vein) subcutaneous (injected into the fatty tissue just under the layer of skin)

  29. IV Injections Subcutaneous A subcutaneous injection is a method of administering medication. Subcutaneous means under the skin. In this type of injection, a short needle is used to inject a drug into the tissue layer between the skin and the muscle. Medication given this way is usually absorbed more slowly than if injected into a vein, sometimes over a period of 24 hours.

  30. IV Injections Intravenous Hypodermic injection into a vein for the purpose of instilling a single dose of medication, injecting a contrast medium, or beginning an IV infusion of blood, medication, or a fluid solution, such as saline or dextrose in water. Allows larger amounts of fluid to be administered and provides means for rapid absorption of medication.

  31. IV Injections Intra-arterial Under special circumstances providers do inject substances into an artery, taking all precautions needed to e.g. prevent blood spill or bleeding afterwards, e.g. injecting blood vessel dilatory drugs like Methyldopa in conditions: where arteries spasm causing lack of blood mostly in hand/feet fingers/toes in Raynaud's disease, in inoperable tumors sometimes blood clots or other solids are injected into the artery that feeds the tumor, thus causing the tumor to (partially) die off because of the lack of blood feeding it so slow the growth and make it more sensitive to chemotherapy and radiation treatment (i.e., Catheter Embolization), and then in rare cases chemotherapy is administered into the artery feeding the tumor which might be in the pancreas, liver, and brain.

  32. IV Push Injection 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.

  33. IV Push Injection Code CPT 96374 to report an IV push injection of a single or initial substance/drug. Code CPT 96375 for each additional sequential IV push of a new substance drug Code CPT 96376 for each additional sequential IV push of the same substance drug For facility coding, do not report 96376 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, 3rdQuarter, Volume 6, Number 3

  34. IV Push Examples Patient given four IV pushes of Demerol, you would assign: 96374 or 96375 depending on whether there were other drug administration services provided and 96376 x3 (provided there was 30 minutes or more between each push).

  35. IV Push Examples Patient given one IV push of Demerol and one IV push of Toradol Assign 96374 and 96375 (again depending on whether there was another initial service) If another initial service was already reported, then assign 96375 x2 since these are two different substances

  36. IV Push Examples Patient given one IV push of Demerol and one IV push of Toradol Assign 96374 and 96375 (again depending on whether there was another initial service) If another initial service was already reported, then assign 96375 x2 since these are two different substances

  37. 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 96372 for vaccines/toxoids

  38. Hydration Therapy 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

  39. Hydration Therapy 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

  40. Hydration Therapy 96360 IV infusion, hydration; initial, 31 minutes to 1 hour Do not report 96360 if performed as a concurrent infusion service Do not report IV infusion for hydration of 30 minutes or less 96361 - each additional hour Report 96361 for hydration intervals of greater than 30 minutes beyond 1 hour Report 96361 to identify hydration if provided as a secondary or subsequent service after a different initial service is administered through the same IV access.

  41. Documentation Guidelines 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

  42. Documentation Guidelines 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

  43. Documentation Guidelines 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.

  44. Documentation 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.

  45. Start & 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.

  46. 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

  47. 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.

  48. Case Scenario 1 Patient comes to the ED on 02-15-15, and hydration is started at 10:00 p.m. It continues until 6:30AM on 02-16-15. 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?

  49. 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)

  50. 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 96372 to report this service?

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