ED Coding and Reimbursement Alert

Nurses or physicians perform injections, in which they deliver medications or blood products to the patient. Make sure you check the documentation to be certain you are coding for the right injection type; 90782 is not the right choice for all types of injections, Edelberg says.

The claim should prove that the proper type of injection code - subcutaneous or intramuscular,  intra-arterial, intravenous or intramuscular - was used to represent the injection on the claim.

"Each code represents [a single] injection," Edelberg says. "One unit of each code may be billed each time there is a separate injection that meets the definition of the CPT code."

Example: A patient reports to the ED with a severe migraine headache, and the nurse gives him a shot of Demerol. Report 90782 for the shot, because injections for migraine headaches meet the criteria for 90782. Other examples of shots coded with 90782 are injections of anti-nausea drugs or vitamin B-12.

Watch for Exceptions

Exceptions: Do not use 90782 for allergy shots, vaccine administration, trigger point injections or arthro-centesis/joint injections. They have their own code groups in CPT.

Hot tip: Locate a copy of Addendum B, Final Rule for the 2004 outpatient prospective payment system (OPPS) payment amounts for separately paid drugs, Edelberg says.

"The addendum tells you what drugs over $50 can be reimbursed separately," Edelberg says. "If you don't have a copy of the most recent addendum, someone else in the hospital will."

Report Infusion Differently Depending on Payer

Infusion coding can be difficult, largely because Medicare has different rules for reporting infusions than other payers.

A physician performs an infusion when he administers drugs intravenously for a prolonged period. You should report infusions to Medicare with Q0081 (Infusion therapy, using other than chemotherapeutic drugs, per visit).

For private carriers, use 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) for the first hour and +90781 (... each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]) for each additional hour.

One and Only One

Although you code injections individually, you can  report only one infusion code per office visit diagnosis. Edelberg says that "an infusion must be medically necessary, and must be supported by documentation."

"CMS says allowable infusion therapy describes infusions of antibiotics for infection or complicated wounds; compazine for severe nausea; and fluids for dehydration," Edelberg says. Report Q0081 once per visit per diagnosis regardless of the number of bags of fluid.

Example: A dehydrated patient reports to the ED after falling asleep at the beach. The physician administers 102 minutes of IV treatment and dismisses the patient. Report Q0081 for Medicare, and report 90780 and 90781 for private carriers.

Remember that the private-carrier infusion codes are time-based in all settings, so document time down to the minute when using 90781. There aren't many codes that are time-based in the ED, but this happens to be one in which good timekeeping can influence an ED claim. Experts recommend recording several bedside assessments per hour during infusions to ensure sufficient documentation.

Warning: You can't always tell what's covered under the infusion therapy guidelines, because what's included often varies by carrier. Check with the carrier for specifics on its interpretation of coverage for infusion services. Most carriers will pay for IV infusion that is medically necessary. As for push medications, "most carriers will accept an IV infusion with the IV push drug, 90784, with modifier -59 (Distinct procedural service) to show that it was a distinct, separate procedure," Marsh says. Others, however, will not.