Facility Infusions: Free the Confusion
Justified scrutiny calls for coding change.
By Sarah L. Goodman, MBA, CPC-H, CCP, FCS
Although proper coding for infusions in the facility setting isn’t a new topic, it still fosters much confusion. Not only is the facility setting more complex by nature, but the codes themselves can be elusive. Because so much confusion exists, infusion services have been scrutinized in recent months by the Office of the Inspector General (OIG) and Recovery Audit Contractors (RACs).
This Tangled Web We Weave
Reporting infusion and injection services has changed dramatically over the past several years, including extensive code renumbering effective Jan. 1, 2009. The key to properly reporting infusion and injection services is documenting start and stop times, not simply the infusion flow rate. The name and dosage of each substance, the route of administration, and the vascular access site location are paramount to appropriate coding and reimbursement. This information will enable you to report on the claim the corresponding drugs or fluids using the applicable HCPCS Level II and/or revenue codes. Most payer systems edit for this.
Hierarchy Can Stump Seasoned Coders
Even with all the aforementioned documented appropriately, there is still the daunting hierarchical coding structure. This can be a challenge to even the most experienced coder — not to mention all the others responsible for charge capture in the facility setting.
Use the following hierarchy to select the initial service code:
- Chemotherapy, initiation of prolonged infusion (greater than eight hours, requiring pump)
- Chemotherapy infusions
- Chemotherapy injections
- Non-chemotherapy, initiation of prolonged infusion (greater than eight hours, requiring pump)
- Non-chemotherapy, diagnostic/therapeutic infusions
- Non-chemotherapy, diagnostic/therapeutic injections
- Hydration infusions
The initial code often does not coincide with the provided infusions or injections sequence, which makes appropriate code selection even more difficult. Charges for infusion and injection services are almost always hard-coded in the charge master and must be entered at the time of service. If facility staff isn’t trained properly in their use, or if the charge encounter forms or order entry screens haven’t been updated or are out-of-synch, compliance issues invariably ensue.
For example, a patient presents to the emergency department (ED) at 9:52 a.m., and an infusion of normal saline 1,000 cc for hydration is ordered and begun. At 10:30 a.m., an intravenous (IV) push of Ondansetron 4 mg is administered. The normal saline infusion is discontinued at 11:00 a.m.
For this scenario, you would code:
- 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug (for the ondansetron IV push)
- 96361 Intravenous infusion, hydration; each additional hour (for the normal saline infusion)
- J2405 Injection, ondansetron hydrochloride, per 1 mg x 4 (for the 4 mg of ondansetron)
- J7030 Infusion, normal saline solution, 1000 cc (for the 1,000 cc of normal saline solution)
Because of its position on the hierarchy, the IV push, although administered subsequently to the start of the hydration infusion, becomes the initial service.
Now consider the same example, but with an infusion of ciprofloxacin beginning at 11:25 a.m. and ending at 12:30 p.m.
In this case, report:
- 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour (for the ciprofloxacin infusion)
- 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (for the ondansetron IV push)
- 96361 (for the normal saline infusion)
- J0744 Injection, Ciprofloxacin for intravenous infusion, 200 mg x 2 (for the 400 mg of ciprofloxacin)
- J2405 x 4 (for the 4 mg of ondansetron)
- J7030 (for the 1,000 cc of normal saline solution)
Although it is administered last, the infusion takes precedence over the IV push and hydration, and becomes the initial service because non-chemotherapy, diagnostic/therapeutic infusions precede injections and hydration infusions in the hierarchical structure.
Separately Billable Haziness Cloud up Coding Decisions
A number of related services and supplies in infusion and injection services are often performed or provided by other departments or staff in the facility setting. These include:
- Use of a local anesthetic
- IV start
- Access to indwelling IV, subcutaneous catheter, or port
- Line flush
- Routine supplies such as tubing or syringes
Facility departments providing the above items and services want to get credit for their part in the process by submitting a charge for their services. Unfortunately, this conflicts with correct coding guidelines, and affects infusion and injection reporting. Simply put, these services and supplies are not separately billable with infusion therapy.
Sometimes a patient presents to a hospital-based clinic with an order for infusion and injection services. If the sole reason for such an outpatient encounter or visit is infusion therapy, an evaluation and management (E/M) service, such as 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, customarily should not be charged in addition, even if nursing triages the patient and/or spends extensive time providing education or counseling services. It is inappropriate for facility staff members to submit a separate E/M in such instances.
Infusions started in an ambulance may be billed separately when properly documented, including the first hour received at the hospital and subsequent hours as necessary (see CMS Transmittal 785, Dec. 16, 2005). The key here again is documentation. While the ambulance run sheet will note an infusion started en route, facility staff must review and record such information in the medical chart. Unfortunately, this often gets overlooked in emergent situations.
Clarity Starts with the Medical Record
What can you do to clear up the confusion? Facilities should start by ensuring medical record documentation includes:
- An order and diagnosis for the service, which supports medical necessity;
- The name and dose (units/concentration) of drugs or substances provided;
- The route of administration (e.g., injection, push, infusion);
- The time the service was provided, including start and stop times for infusions and whether the infusion was initially started via ambulance; and
- The provider’s initials or signature.
Facilities should review and update their charge masters and related charge capture tools on a regular basis and educate staff accordingly. If a Medication Administration Record (MAR) is utilized for capturing infusion services, retain it in the medical chart for audit purposes.