ED Coding and Reimbursement Alert

Question: When we see observation patients, we aren’t sure how to report infusions on multiple days. Our current process is to treat the entire observation stay as one encounter. For example, if we have a push on the first date and then an infusion on the second date, followed by three hours of hydration, we would charge as follows:

Day one: 96374 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; intravenous push, single or initial substance/drug)

Day two: 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour) and +96361 x3 (Intravenous infusion, hydration; each additional hour [List separately in addition to code for primary procedure]). Is this the correct process to follow?

Codify Subscriber

Answer: When sequencing codes in this category, a single primary code may be used only one time within an encounter unless you experience the relatively rare situation where protocol or patient condition requires a separate IV site to be used. The Correct Coding Initiative (CCI) has an edit in place barring you from billing 96374 with 96365 during the same encounter, likely because both are considered “initial” codes and you would only have to set up the IV line once. However, you typically do not need to report them in the order in which you performed the injections.

When the codes are being reported by the facility, you must follow CPT^®’s hierarchy, which dictates that chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services, which are primary to hydration services. Infusions are primary to pushes, which are primary to injections.

When you are billing for the facility, the infusion code is primary, despite the fact that it wasn’t the first service performed. Therefore, you would report 96365 for the infusion, followed by +96375 (…each additional sequential intravenous push of a new substance/drug [List separately in addition to code for primary procedure]) for the push, and then three units of +96361.

Here’s why: CPT^® specifically says in its notes following +96375 that it can be used as an add-on code with 96365, even though it is listed in CPT^® directly following the descriptor for 96374.