ED Coding and Reimbursement Alert

Time, primary codes are of high importance when coding these services.

Every emergency department administers infusions from time to time, but not every ED coder is familiar with the nuances of reporting these services. In many cases, you’ll have to not only select the right code, but also count up the time that the provider spent on the infusion.

Check out these tips to confirm that you’re reporting infusions correctly.

First, Know When Infusions Occur

An infusion is an intravenous medication in a volume of fluid that is infused over a period of time greater than 15 minutes. Many EDs document an infusion as an “IVPB” (intravenous piggyback) or as a “drip.” You should report an infusion of less than 15 minutes the same as an intravenous injection or IV push medication, CPT® guidelines indicate.

Keep in mind that codes 96360-96379, 96401, 96402, 96409-96425, and 96521-96523 are not intended to be reported by the physician in the facility setting; rather, these would be facility charges, as stated in the CPT^® code book.

Know the rules: Correct sequencing of infusion codes is essential for proper code assignment. CPT^® guidelines specify that you must report just one primary code for an infusion service, and you can then append add-on codes for more services administered through the IV line, or more time. Examples of the primary codes are:

• 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour)
• 96369 (Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s))

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 you face the relatively rare ED situation where protocol or the patient’s condition requires a separate IV site to be used.

In black and white: “When administering multiple infusions, injections, or combinations, only one ‘initial’ service code should be reported for a given date, unless protocol requires that two separate IV sites must be used,” CPT^® states.

If you must insert two separate IVs, then CPT^® rules dictate that you’ll report the primary code twice, with a modifier appended to the second line item, as follows:

• 96365
• 96365-59 (Distinct procedural service)

This happens on occasion when a patient requires two separate IVs, but many payers will question the situation, so maintain detailed records showing why and where the extra IV insertion took place.

Keep an Eye on the Clock

CPT^® has established “hierarchies” of codes in this category for the facility side so the coder can determine which to report as the initial service.

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 a previous infusion. These infusions are typically 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 (… concurrent infusion (List separately in addition to code for primary procedure)) and only one time per date of service. Additional hours of infusions are reported with the add-on code +96366 (… each additional hour (List separately in addition to code for primary procedure)). This add-on code may be used in conjunction with 96365 and +96367.

Get the Point of IV Push Codes

In some situations, the ED provider will inject a medication directly into the IV line, and that’s known as an “IV push.” In this situation, you’ll report the initial service with 96374 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug).

If you then inject a different medication through the line, report code +96375 (…each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)) once per substance.

Differentiate Hydration

The above codes typically refer to infusions of medications, but the coding rules change if you’re reporting hydration provided via IV infusion. In this situation, you’ll report the initial service with 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 typically sequenced after infusions and injections.

Hydration example: The ED physician orders two liters of IV hydration for a 63-year-old male patient with a diagnosis of viral gastroenteritis and dehydration. The hydration begins at 12 noon and runs until 2:05 pm, at which time the two liters have been completed. On the claim, report 96360 for the first hour, and one unit of +96361 for the second hour of the hydration service.

Keep in mind: Most insurers will only pay for hydration if you can prove medical necessity — in other words, you can’t simply collect for hydration just because it’s part of your ED’s routine to insert a hydration line for every patient with a particular condition.

In black and white: “It is important to distinguish the medical necessity of hydration from the use of fluid administration intended only to initiate flow or to keep the vein open,” CMS says in Bulletin 0137. “When the sole purpose of the IV fluid administration is to establish and/or maintain vascular access or patency of the IV line, the service is neither diagnostic nor therapeutic and must not be separately reported,” CMS says.

Timing Is Everything 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. Many of these codes refer to an hour, so if you don’t keep track of the time, you won’t know when add-on codes are reportable.

ED coders should be aware that there are many National Correct Coding Initiative (NCCI) edits associated with this entire group of services, and you may need to apply a modifier to indicate a separate procedure. In addition, many of these codes are bundled with one another. For example, NCCI restricts you from reporting 96374 with 96360 together unless you can demonstrate the separate nature of these services. In most cases, you won’t be able to report them together unless you used separate sites for the infusions.