Straighten Out the Kinks in Your Infusion Road Map
Navigate with ease through the complexity of non-chemotherapy infusion encounters.
Coding infusion services can seem as complicated as driving to an unknown destination without GPS, especially when there are multiple medications. Whenever you’re feeling lost, use this road map for facility-based billing of non-chemotherapy medications to find your way to proper payment.
First Stop: Hierarchies
Unlike physician coding, when coding facility infusions, the initial code is determined by using a hierarchy. The hierarchy sequence is infusions, intravenous (IV) pushes, injections, and hydration.
Example: If a patient received one hour of hydration and later in the evening received a one-hour infusion of non-chemotherapy medication, code an initial infusion (CPT® 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour) followed by a subsequent hydration (CPT® +96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)).
It’s important to remember this hierarchy when reviewing facility coding; do not code based on which procedures occurred first throughout the day.
With an understanding of the coding hierarchy, let’s direct our focus on the initial infusion. CPT® 96365 reports the initial hour of infusion. Add-on codes are reported for additional hours of infusion only after more than 30 minutes have passed from the end of the previously billed hour. A breakdown of this is 16-90 minutes for the first hour of infusion, 91-150 minutes for the second hour, 151-210 minutes for the third hour, and so on.
To report additional hours of infusion, use CPT® +96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) when the medication is the same as the initial infusion, and CPT® +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) when the medication is different from the initial infusion.
Fork in the Road: Concurrent Infusions
It’s a smooth ride until you meet a fork in the road, also known as concurrent infusions. When additional infusions are provided at the same time, through the same IV line, in two different bags, a concurrent code is reported (CPT® +96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)). Note that when drugs are mixed into one bag and infused, this does not constitute a concurrent infusion; code this as a single infusion (for example, 96365).
When two drugs are infused at the same time, through the same line, in two different bags, report CPT® 96365, initial infusion (for medication A) and concurrent CPT® 96368 (for medication B). Unlike the infusion codes, the concurrent code is not time-based and may be reported once per day, even if additional medications are administered concurrently.
Note that hydration is never billed as a concurrent service. Hydration that overlaps an infused medication is considered an incidental service and is not billable. According to Noridian, Jurisdiction E Medicare Administrative Contractor, “If the purpose of starting the IV is to administer another drug, which requires hydration (i.e., the drug indication directs the administration be done with hydration to prevent toxicity), then the hydration is an integral part of the primary medication and is not separately billable.”
Hydration given solely to keep the IV line open is also not a billable service. If hydration is truly a separate service and documentation supports medical necessity, this service is billed using an add-on code (+96361) when another service is reported as initial.
When multiple intravenous medications are administered during the same encounter, remember that only one initial code is reported; all other intravenous medications are reported with a subsequent service code. The exception to this rule is if protocol requires two separate IV sites.
Remember: The CPT® code book explains, “Do not report a second initial service on the same date due to an intravenous line requiring a re-start, an IV rate not being able to be reached without two lines, or for accessing a port of a multi-lumen catheter.”
Turn to 59 Only if Two Separate Locations Exist
If documentation truly does support two separate IV sites, append modifier 59 Distinct procedural service. Do not use modifier 59 with initial and subsequent codes, even if different medications were used. Modifier 59 is only allowed if applied to separate anatomical locations within the same encounter.
Per the National Correct Coding Initiative (NCCI) Policy Manual, “Separate reporting of a procedure designated as a ‘separate procedure’ when it is performed at the same encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach is not allowed.”
A common misuse of modifier 59 is when an infusion and a push are given during the same encounter. Although there are distinct differences between infusions and pushes, the medication is still administered to the same anatomical location, making the use of modifier 59 inappropriate.
It’s common to see multiple pushes given to a patient within a short period of time. If this occurs, CPT® guidelines say that at least 30 minutes must elapse between pushes of the same medication. If different medications are being administered, however, then the 30-minute elapse is not required.
If an order states “infusion,” but the medication duration is 15 minutes or less or the infusion stop times are missing, it’s appropriate to bill a push using CPT® codes:
96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug; and
+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) for a subsequent push of a different medication; or
+96376 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure) for a subsequent push of the same medication.
Examples Keep You Headed in the Right Direction
Let’s review an example:
A patient presents to the ER and is initially given hydration from 4 p.m.-5 p.m. The patient’s condition worsens, and a push of medication A is given at 7:15 p.m. and a subsequent push of medication B at 7:20 p.m. The patient then receives an infusion of medication C from 10 p.m.-1 a.m. (the next day). Keeping in mind the hierarchy, how would you code this?
Start with the infusion: Medication C was given for 180 minutes. This is coded:
- 96365 for the initial infusion
- +96366 with 2 in the QTY box for the additional hours
This infusion was all the same medication, so do not use CPT® +96367.
Next, code the pushes. You already billed an initial code, so now use the subsequent codes:
- +96375 with 2 in the QTY box for the additional hours
These are different medications, so do not use CPT® +96376. And because these are different medications, it’s OK that the administration of these medications was not 30 minutes apart.
Lastly, code the hydration:
- +96361 (subsequent code)
During this encounter, the documented hydration time was separate from the infusion, making it a billable charge.
What a Trip!
It feels like we’ve been driving all night. Speaking of all-nighters, what about that infusion service that carried over to the next day? When an infusion crosses over to the next day, bill it with the date of service it started on. Per CMS, only one initial drug administration service is reported per vascular access site, per encounter, even when those services span over more than one calendar day.
About the author:
Jessica Webb, COC, CPCO, has been in the healthcare industry since 2008. She works at Oregon Health and Science University as an integrity auditor, performing both physician and hospital-based audits.
CPT® code book
Noridian, Jurisdiction E – Medicare Part A, Hydration.
CMS, NCCI Policy Manual. Chapter 1. www.cms.hhs.gov/NationalCorrectCodInitEd/