Eliminate INFUSION Confusion

Proper coding of drug administrations in non-facility settings starts with good documentation.

By Maryann C. Palmeter, CPC, CPCO, CENTC, AAPC Fellow
For infusion/injection administration, “good” documentation begins with a physician’s order that provides the name of the drug, dosage, and reason for its administration. From a best practice perspective, documentation also should include a record that lists the drug source, lot number, expiration date, and patient on whom the drug was administered. How each substance was administered (route) and the site of each administration also must be documented.
The time each substance was administered also should be included in the documentation to properly sequence multiple administrations. CPT® and Medicare do not specifically require start and stop times for drug infusions, but documenting these times will save the coder the need to calculate infusion time based on volume, rate, and intravenous (IV) calibration. Coders must not assume infusion time based on a physician’s order alone because there is always the possibility that the infusion had to be stopped or discontinued. Also, the physician’s order may not take into account IV calibration.

Know the What, How, Where, When, and Why

Coding for the administration of injections and infusions requires you to know five key pieces of information:

1. What – Tells the substance/drug/agent administered so you can select the proper subheading (e.g., hydration, therapeutic, chemotherapy) for the administration.
2. How – Tells by which route the substance entered the bloodstream (e.g., intra-arterially, subcutaneously, via IV infusion, etc.), and helps to further define code selection.
3. Where – Tells the site injected (e.g., right deltoid) or where the IV line was placed (e.g., left hand). This also helps with modifier application and coding of multiple administrations.
4. When – Tells us at what time each substance was administered and total infusion time. This helps with code selection, unit selection, and sequencing.
5. Why – Supports medical necessity and helps with sequencing (i.e., the primary reason for the encounter).

Look at What Is Bundled and What Isn’t

Services performed to facilitate the infusion or injection—such as the use of local anesthesia, IV start; access to an indwelling IV, subcutaneous catheter or port; flush at conclusion of infusion; and standard tubing, syringes, and supplies—are not to be reported separately.
If the physician practice purchased the drugs/substances, the corresponding HCPCS Level II codes may be reported in addition to the administration codes.
Per CPT®, if a significant, separately identifiable evaluation and management (E/M) service is performed it may be reported in addition to the administration codes. Some private payers have rules that contradict CPT®, however, so be sure to research specific payer contracts and policies.

For Hydration See CPT^® 96360-96361

Hydration is administered only by IV infusion and is used to report the administration of prepackaged fluids and electrolytes (e.g., normal saline, D5W), not drugs or other substances. A minimum of 31 minutes is required to report the first hour of hydration.
Hydration is bundled when performed concurrently with other infusion services; however, hydration may be reported if provided secondary or subsequent to a different initial service administered through the same IV access. Hydration may also be billed separately if provided prior to the primary substance. (See definition of Sequential in the accompanying Key Definitions sidebar.)

Consider Therapeutic, Prophylactic, and Diagnostic Infusions/Injections Key Points

There are some key points to consider regarding therapeutic, prophylactic, and diagnostic infusions/injections (CPT® 96365-96379). For example, codes describing these procedures are not used for:

• hydration or vaccines/toxoids
• allergen immunotherapy
• antineoplastic hormonal or nonhormonal therapy
• hormonal therapy that is not antineoplastic
• chemotherapy
• highly complex drugs
• highly complex biologic agents
• therapeutic, prophylactic, and diagnostic infusions/injections, which require direct physician supervision for patient assessment, provision of consent, safety oversight, and intra-service staff supervision

Do not report 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular injection if the substance was administered without direct physician supervision. You might instead refer to 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician … Note, however, that Medicare also requires direct physician supervision to bill 99211. If the physician does not provide direct supervision, neither 96372 nor 99211 may be billed to Medicare. If the administration code cannot be billed, neither can the drug/substance administered.
Infusions require:

• special consideration to prepare, dose, or dispose of;
• practice training and competency for the staff who administer them; and
• periodic patient assessment with vital sign monitoring.

Apply Chemotherapy and Other Highly Complex Drugs or Biologic Agents Rules

CPT® 96401-96549 apply to parenteral administration of nonradionuclide antineoplastic drugs, antineoplastic agents provided for treatment of noncancer diagnoses, substances such as certain monoclonal antibody agents, and hormonal antineoplastics.
Per CPT®, because of the complex nature of the drugs involved, the administration requires advanced practice training and competency for staff who provide them, and special consideration for preparation, dosage or disposal. Physician work and/or clinical staff monitoring of the patient goes well beyond that of therapeutic drug agents because there is a greater risk of severe, adverse patient reactions. Do not report preparation of the chemotherapy/complex drug/biologic agents when performed to facilitate the infusion or injection.
Direct physician supervision is required for patient assessment, provision of consent, safety oversight, and intra-service supervision of staff.
Report each parenteral method of administration employed when chemotherapy/complex drug/biologic agents are administered by different techniques. When independent or sequential administrations of medications are administered as supportive management, report in addition to chemo/complex/biologic agent codes. CPT® does not include a code for concurrent chemotherapeutic infusion because chemotherapeutics are not usually infused concurrently. If a concurrent chemotherapy infusion were to occur, CPT® instructs us to use the unlisted chemotherapy procedure code 96549 Unlisted chemotherapy procedure.
Example: A patient presents for chemo treatment. He is provided an antiemetic to help with anticipated nausea, and is also given a B12 injection for anemia. IV infusion of antiemetic drug X in left arm, start 14:50/end 15:25. IV infusion chemo drug A same site, start 15:30/end 16:45. At 16:55 patient receives B12 injection IM in right hip (ventrogluteal). Physician provides direct supervision.

• Start with the primary reason for the encounter (patient presents for chemo treatment, sequence accordingly).
• Code IV chemo infusion as the primary service.

Code IV chemo infusion based on time for single substance/drug (96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for up to one hour. Total infusion time was one hour and 15 minutes. Per CPT®, do not report the additional hour code 96415 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure) unless the infusion interval is greater than 30 minutes beyond the hour increments. In this case, the infusion interval after the initial hour was only 15 minutes so you would not report 96415.

• Follow with IV infusion of prophylactic antiemetic drug X.

Report 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (list separately in addition to code for primary procedure) because the infusion was provided subsequent to the chemo service and was administered through the same IV site. Remember, if injection or infusion is subsequent or concurrent in nature, even if it is the first such service within that group of services, report the subsequent or concurrent code from the appropriate section.

• End with therapeutic injection of B12 administered intramuscularly by coding 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); substance or intramuscular (physician provided direct supervision).
  • Correct coding is: 96413 x 1, 96367 x 1, 96372 x 1.
  • Don’t forget to include the HCPCS Level II codes for the drugs administered.

Understand Correct Sequencing

For physician billing in a non-facility setting, report as the “initial” service the code that best describes the key or primary reason for the encounter, irrespective of the order in which the infusions or injections occur. This is different than for facility settings where sequencing rules require administrations to be coded in the following order:

• Chemotherapy/Complex
• Therapeutic, prophylactic, diagnostic
• Hydration

For facility billing, infusions are coded before pushes and pushes are coded before injections.
Example: Patient presented for chemo treatment. IV infusion of chemo drug C, start 09:00/end 11:00. Piggyback infusion of Tx drug D, start 09:45/end 10:45. Prophylactic drugs A and B mixed together and administered via IV infusion prior to chemotherapy, start 7:55/end 8:55. All infusions are via same site and the physician provided direct supervision.

• Start with the primary reason for the encounter (patient presents for chemo treatment, sequence accordingly).
• Code 96413 x 1 for the first hour of infusion chemo drug C.
• Code 96415 x 1 for the second hour of infusion chemo drug C.
• Code 96367 x 1 for one hour infusion of pro drugs A & B mixed together.

Count drugs mixed together as one infusion; and code them as sequential even though they were administered prior to the chemo. Per CPT® Assistant, when administering multiple infusions, injections, or combinations, only one “initial” service code should be reported, unless administration occurred through separate IV sites—even if subsequent or concurrent in nature and even if it is the first such service within that group of services. Although this is the first prophylactic infusion, it would be coded as subsequent because chemo drug C is coded first per physician sequencing rules. Remember: Subsequent can mean administered before or after the initial drug.

• Code 96368 x 1 for one-hour concurrent infusion of Tx drug D (note Piggyback).
• Correct coding is: 96413 x 1, 96415 x 1, 96367 x 1, 96368 x 1.
• Don’t forget to include the HCPCS Level II codes for the drugs administered.

Multiple Administrations

If the injection or infusion is subsequent or concurrent in nature, even if it is the first such service within that group of services, report the subsequent or concurrent code from the appropriate section. More than one initial service code is only appropriate when there are separate IV sites (e.g., IV right hand and IV left hand) or separate encounters (e.g., visit at 8 a.m. and separate encounter at 3 p.m. on the same day).
Append modifier 59 Distinct procedural service to identify the distinct procedural service when more than one initial service code is justified. Some payers may accept RT Right side and LT Left side modifiers, instead of modifier 59, to signify separate sides of the body.
Example encounter 1: Cancer patient receives IV infusion of antineoplastic drug, start 08:05/end 11:10.
Example encounter 2, same day: Patient returns for administration of hydrating solution provided via IV infusion for dehydration, start 14:20/end 16:30. New line started.

• Code 96413 for the first hour of IV infusion of the chemo drug (antineoplastic drugs are coded under chemo/complex/biologic agent subheading).
• Code 96415 for each additional hour.

There were two additional hours beyond the first hour so, two units are reported.

• The patient returned during a different encounter: Because new IV access had to be established to infuse the hydration solution, select code 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour for IV infusion, hydration; initial for the first hour.
• Code 96361 x 1 for the additional hour of hydration.

According to CPT® instructional notes, if the hydration solution had been administered through the same IV access as a secondary or subsequent service to the chemo infusion, we would have coded ALL of the time for hydration with code 96361 Intravenous infusion, hydration; each additional hour (list separately in addition to code for primary procedure) instead of splitting out into initial and additional codes. The key here is different IV access. Because the patient returned and a new IV access had to be established, start with the initial hydration code and code any additional hours with add-on code 96361.

• Append modifier 59 to identify the hydration service codes as distinct, procedural services because the hydration was performed during a separate encounter.
• Proper coding for both encounters is: 96413 x 1, 96415 x 2, 96360-59 x 1, 96361-59 x 1
• Don’t forget the HCPCS Level II codes for the drugs.

To code administrations properly, it is important to understand these key terms.
Push – Also known as a bolus, is medication administration from a syringe directly into an ongoing IV or intra-arterial infusion or saline lock. Per CPT^®, if a health care professional administers a substance/drug intravenously or intra-arterially, and is continuously present to administer and observe the patient, the administration is treated as a push. Continuous presence must be documented. If the infusion time is 15 minutes or less, the administration is treated as a push.
Concurrent – Multiple drugs or substances infused simultaneously through the same line. Multiple substances mixed in one bag are considered one infusion, not a concurrent infusion.
Piggyback – Infusion of medication given on top of the main solution that allows for the intermittent infusion of different medications at specific times. See also Concurrent.
Sequential – Initiation of different fluid or drug administered immediately following the primary substance. It may also be referred to as secondary. Note: Sequential can also refer to drugs/substances administered before the primary substance.
 

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Maryann Palmeter

Maryann C. Palmeter, CPC, CPCO, CPMA, CENTC, CHC, has more than 30 years of technical and executive level experience gained through her work on both the government payer and professional billing ends of the healthcare spectrum. She is director of physician billing compliance at the University of Florida Jacksonville Physicians, Inc., and is responsible for providing professional direction and oversight to the billing compliance program of the University of Florida College of MedicineJacksonville. Palmeter served on the AAPC’s National Advisory Board from 2011-2013 and was subsequently selected to serve as secretary for the 2013-2015 term. She was named the AAPC’s 2010 “Member of the Year” and is the vice president for the Jacksonville, Fla., local chapter.

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