Infuse Yourself with Coding Knowledge
Tips and tricks for proper drug administration coding.
by Amy Lee Smith, MBA, CPC, CPC-H, CPMA, CIA, CRMA
If the profuse number of Office of Inspector General (OIG) audits showing improper payments for drug claims submitted to Medicare every year is any indication, it’s safe to say that drug administration coding can get sticky. Proper drug administration coding requires as much precision as the services themselves. Just like clinicians learn little tricks for properly injecting drugs, however, there are several tips and tricks you can use to pick the right code every time.
Drug Administration Basics
First, remember that there are three categories of drug administration:
- Hydration: CPT® codes 96360-96361 are for pre-packaged fluids and electrolytes. These codes are not used to report infusion of drugs or other substances and are not reported by the physician in a facility setting.
- Therapeutic/Prophylactic/Diagnostic: See Table 1 for CPT® codes to report for the administration of drugs and other substances (other than hydration). Do not report these codes for chemotherapy or other highly complex drugs/biological or when fluids are used to administer the drug(s); the fluid administration is incidental hydration and is not separately reportable. These codes are not reported by the physician in a facility setting.
- Chemotherapy or other biologic agents/complex drugs: See Table 2 on the next page for appropriate CPT® codes. “Chemo” includes other highly complex drugs or biologic agents such as:
- Non-radionuclide anti-neoplastic drugs
- Anti-neoplastic agents provided for treatment of non-cancer diagnoses
- Certain monoclonal antibody agents
- Other biologic response modifiers
Use of these codes typically requires advanced practice training and competency; special considerations for preparation, dosage, or disposal; and usually entails significant patient risk and frequent monitoring far beyond that of therapeutic administrations. Physicians in the facility setting may not use chemotherapy codes.
Report separate codes for each method of administration when chemotherapy is administered by different techniques. Medications administered independently as supportive management of chemotherapy are reported separately using 96360, 96361, 96365, or 96379, as appropriate.
Along with three categories of drug administration, there are three methods by which drugs may be administered:
- Injection: Do not use CPT® 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular for the administration of vaccines/toxoids. This code does not include injections for allergen immunotherapy. Although hospitals may report injection codes when the physician is not present, physician offices may not. You may use injection codes to report non-antineoplastic hormonal therapy.
- IV Push: CPT® 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug is appropriate when intravenous (IV) push is the primary service. Add-on code +96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) may be reported with 96365, 96374, 96409, or 96413 to identify an IV push of a new drug when provided as a secondary service after a different initial service is administered through the same IV access.
Add-on code +96376 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility drug (List separately in addition to code for primary procedure) is used only when the same drug is administered twice in one encounter, but not within 30 minutes of each other. All of these IV push codes are reported for facilities only, and may be used for infusions lasting 15 minutes or less.
Infusion: Refer to Table 1 on the preceding page for infusion codes and their instructions.
What makes your job so sticky is that these categories and methods can be combined in a number of different ways, all of which are coded differently.
Determine the “Initial” Service
The American Medical Association (AMA) created different codes for “initial” and “subsequent” administrations; coding guidelines state there should be only one initial code per encounter, unless two separate access sites are required. So how do you determine what the initial service is when more than one method or category of administration is provided?
Although the rules vary depending on where the service is provided, the actual chronological order of administration is not important for coding. The initial code is not necessarily the first service provided.
In the physician practice, the initial service is the primary reason for the visit. For example, a patient comes in for chemotherapy, but also gets an antibiotic injection and a hydration infusion to supplement the chemotherapy. The primary reason for the visit is the chemotherapy so it is the initial service.
In the outpatient facility setting, there is a hierarchy to determine the initial service:
1. Chemotherapy infusions
2. Chemotherapy IV pushes
3. Chemotherapy injections
4. Therapeutic/Prophylactic/Diagnostic infusions
5. Therapeutic/Prophylactic/Diagnostic IV pushes
6. Therapeutic /Prophylactic/Diagnostic injections
The highest-ranking service provided is considered the initial service. For example, a patient comes into a hospital outpatient department for an antibiotic injection, but also receives a hydration infusion. The initial service is the antibiotic injection because the therapeutic injection ranks higher in the hierarchy than the hydration infusion.
Coding for Multiple Administrations
If you can bill only one initial code per patient, per date of service, per IV access site, how do you capture the work when more than one administration is provided during a single encounter?
Specific codes for sequential, subsequent, and concurrent administrations account for additional services provided. Use subsequent or concurrent codes where appropriate, regardless of the administration order (e.g., first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code). Before you make your code selection, it’s important to know time requirements and documentation rules.
One of the biggest obstacles when coding drug administration is the common lack of documentation; start and stop times must be clearly and completely documented in the medical record by the clinician. The start time is normally well documented, but the stop time is quite often omitted. Check with your payer to see their requirements for these situations; some will accept a code for an IV push even if a stop time is not documented, while others will not.
In general, an IV push code may be used for an infusion lasting 15 minutes or less (again, check with your payers for clarification). In drug administration terms, “one hour” means any infusion lasting between 16 and 90 minutes. Only when an infusion lasts longer than 90 minutes can you code the “additional hour” code. “Each additional hour” means increments greater than 30 minutes over the initial hour. Do not include time spent keeping veins open (see Table 3 for examples).
Table 1: Diagnostic/Therapeutic/Prophylactic Infusion Codes
|CPT® Code||CPT® Description||Notes|
|96360||Intravenous infusion, hydration; initial, 31 minutes to 1 hour||Do not report if performed as concurrent infusion service; do not report hydration infusion of 30 minutes or less).
Use for infusions of 31-90 minutes.
|+96361||Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)||Report for intervals of greater than 30 minutes beyond one-hour increments; also report for secondary or subsequent service after a different initial service through same IV access.|
|96365||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour||Report for IV infusions of 16-90 minutes.|
|+96366||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)||Report for intervals of greater than 30 minutes beyond one-hour increments; also report for secondary or subsequent service after a different initial service through same IV access.|
|+96367||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)||Report in conjunction with 96365, 96374, 96409, or 96413 if provided as secondary service after a different initial service is administered through the same IV access.
Report only once per sequential infusion of same infusate mix (multiple drugs mixed together in one bag is one infusate mix).
|+96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)||Report only once per encounter.
Report in conjunction with 96365, 96366, 96413, 96415, or 96416.
Used for infusions running at the same time via the same IV access—must be hung in separate bags.
Table 2: CPT® codes for chemotherapy administration
|CPT® Code||CPT® Description||Notes|
|96401||Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic|
|96402||Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic|
|96409||Chemotherapy administration; intravenous, push technique, single or initial substance/drug|
|+96411||Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure)||Report with 96409 or 96413.|
|96413||Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug||Report for infusions of 16–90 minutes.
Report 96361 to identify hydration as a secondary service through the same IV access.
Report 96366, 96367, or 96375 to identify therapeutic infusion/injection as secondary service through same IV access.
|+96415||Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)||Report in conjunction with 96413.
Report for infusion intervals of greater than 30 minutes beyond one-hour increments.
|+96417||Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug) up to 1 hour (List separately in addition to code for primary procedure)||Report in conjunction with 96413.
Report only once per sequential infusion.
Report 96415 for additional hour(s) of sequential infusion.
Table 3: Reporting infusion time
|Single infusion lasting:||Can be coded
(assuming documentation is complete):
|15 minutes or less||IV push|
|16 – 90 minutes||Initial hour|
|91 – 150 minutes||Initial hour + 1 additional hour|
|151 – 210 minutes||Initial hour + 2 additional hours|
|211 – 270 minutes||Initial hour + 3 additional hours|
|… and so on|
Know What’s Included
The following services are included in all of the drug administration codes, and are not separately reportable:
- Use of local anesthesia
- IV start
- Access to indwelling IV, subcutaneous catheter, or port
- Flush at the conclusion of infusion
- Standard tubing, syringes, and supplies
Chemotherapy administration codes also include preparation of drugs/agents and any fluids used to administer the chemotherapy.
If a significant, separately identifiable evaluation and management (E/M) service is provided, report the appropriate E/M code with modifier 25 in addition to the infusion codes. A different diagnosis is not required; however, you cannot report 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services with infusion codes.
If multiple infusions are administered, report only one initial service code, unless two separate IV sites are required.
- Per the Medicare Claims Processing Manual (chapter 4, section 230.2) as of 2007, only one initial service code can be reported per patient, per date of service, per separate IV access site.
- If there are multiple IV access sites, each site may be coded with an initial code and modifier(s), as appropriate, and must be supported by documentation in the record indicating it is medically reasonable and necessary for the drug or substance administrations to occur at separate intravenous access sites.
Amy Lee Smith, MBA, CPC, CPC-H, CPMA, CIA, CRMA, is a senior manager of internal audit with Bon Secours Health System, Inc., where she primarily performs coding and billing audits. She holds a bachelor’s and a master’s degree in Business Administration with a concentration in finance from The College of William & Mary in Virginia. Ms. Smith is also a Certified Internal Auditor and certified in Risk Management Assurance.