ED Coding and Reimbursement Alert

Base your code selection on hierarchy and length of these hydration injection and infusion services.

When coding on the facility side you'll need to be able to pinpoint the type of solution being provided to the patient (hydration, infusion and injection), the duration of the service, and how to properly sequence the codes.

The administration of Hydration, Injection and Infusion services represent significant ED facility procedures and an important component of accurate ED Facility charge capture.

Soak Up These Hydration Coding Tips

Hydration services include prepackaged fluids and electrolytes such as NS, D5NS and LR to name a few says Sarah Todt, RN, CPC, CPMA, CEDC, Director, Quality & Education for LogixHealth in Bedford, MA.

Infusion refresher: An infusion is an intravenous medication in a volume of fluid that is infused over a period of time greater than 15 minutes. You would document an infusion as an IVPB (intravenous piggy back) or as a drip. You report an infusion of less than 15 minutes the same as an intravenous injection or IV push medication.

Know the rules: Correct sequencing of infusion codes is essential for proper code assignment. CPT® guidelines specify that infusions precede injections and injections precede hydration.

And you'll need to ensure you properly sequence primary and secondary codes. In the sequencing, a single primary code may be used only one time within an encounter unless in the relatively rare ED situation where protocol or patient condition requires a separate IV site to be used. The primary codes include 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour) for initial infusion, 96374 (...intravenous push, single or initial substance/drug) and 96360 for the initial hydration service, Todt adds.

CPT® dictates a hierarchy for the initial use of these services: infusions are primary to pushes, which are primary to injections, which are primary to hydrations, clarifies Todt. Use the primary code in each category only once per claim. (Editor's note: See the You be the Coder case in this issue for examples of the principles discussed in this article)

Prioritize Therapeutic Infusion

Therapeutic infusions are sequenced first when reporting multiple infusions. In addition to the primary service for infusions, 96365, you'll need to consider subsequent and concurrent services.

Watch the clock: Time is your key to determining the proper code assignment. Each hour of service should be reported for each infusion.

Sequential infusion refers to an infusion of a new drug that occurs after another infusion. These infusions are reported with 96367 (...additional sequential infusion of a new drug/substance, up to 1 hour [List separately in addition to code for primary procedure]) per hour of infusion.

An infusion that occurs at the same time as another infusion is a concurrent infusion. You'll report concurrent infusions with 96368 and only one time per date of service. Additional hours of infusions are reported with the add-on code 96366. This add on code may be used in conjunction with 96365 and 96367, says Todt.

Get The Point of These Injection Tips

Intravenous injection codes include the initial service, 96374, as well as two codes for subsequent injections. If the injection is of a different medication, you would report code 96375 once per substance. Sequential injections of the same medication, according to CPT®, may be reported with 96376 unless the injection occurs within 30 minutes after the previous injection, Todt advises.

Hydration services include the initial service, 96360 (Intravenous infusion, hydration; initial, 31 minutes to 1 hour), as well as 96361 (...each additional hour [List separately in addition to code for primary procedure]) for additional hours of infusion. Hydration therapy codes are always sequenced after infusions and injections, regardless of when they occur in the course of care.

When an infusion or injection is reported, you would report the first hour of hydration with 96361. Hydration should not be reported if the fluid is simply used as a vehicle to deliver medication (as with infusions), Todt adds.

Hydration Example: A 53 year old female with a diagnosis of viral gastroenteritis and dehydration has two liters of IV hydration ordered by the ED physician. The hydration begins at 12 noon and runs until 2:05 pm at which time the 2 liters has been completed.  On the claim, report 96360 for the first hour, and 96361 for the second hour of the hydration service.

Watch The Clock for Spot-on Accuracy

Timing is essential when reporting these services. Although start and stop times are not part of the CPT® definitions, they are recommended for best practice documentation, Todt instructs. Many of these codes refer to an hour.

Instructions in CPT® indicate that the timing will be considered met when the half-way point has been crossed. For example, an hour of infusion or hydration therapy may be reported when 31 minutes have elapsed, says Todt.

Look to CCI Edits for Modifier Application

ED coders should be aware that there are many CCI edits associated with this entire group of services, and you may need to apply a modifier to indicate a separate procedure. For example, many of the CPT® codes for CAT scans with contrast will have an edit with injection services. The modifier -59 may be applied to indicate that the injection is not related to the contrast injection for the scan. The use of the 59 modifier should always be validated as appropriate to override the CCI edit before appending, warns Todt.